Professional Documents
Culture Documents
Key Nursing Skills
Key Nursing Skills
BARBARA A WORKMAN
RGN, MSc, BSc(Hons), RNT, RCNT,
Dip N(Lond)
Senior Lecturer, Middlesex University
CLARE L BENNETT
RGN, MA, BSc(Hons), DipN,
PGCHE
Senior Lecturer, Middlesex University
FRANCES GORDON
PhD, MEd, RN, RNT, RCNT
Principal Lecturer, Middlesex University
NORA COOPER
RGN, BA(Hons), PGCEA
Senior Lecturer, Middlesex University
W
WHURR PUBLISHERS
LONDON AND PHILADELPHIA
Contents
Preface
SECTION I
vii
1
Assessment procedures
Chapter 1
19
Observations
Clare Bennett
SECTION II
45
Principles of caring
Chapter 3
47
Infection control
Barbara Workman
Chapter 4
60
Personal hygiene
Frances Gordon
Chapter 5
78
SECTION III
91
93
Drug administration
Barbara Workman
Chapter 7
134
178
Respiratory care
Clare Bennett
Chapter 9
214
235
Elimination
Clare Bennett and Barbara Workman
Chapter 11
275
Aseptic procedures
Barbara Workman
Chapter 12
307
vi
323
331
Preface
The authors, who all have wide experience in teaching and practising
adult nursing, collaborated to write this book, which evolved from a
clinical skills module. It became apparent that students loved learning
the introductory nursing skills, but there were few easily accessible
texts to support their learning. This book is therefore aimed at nursing
students embarking on their nursing education, although some of it
will also be suitable for care assistants who are involved in delivering
direct nursing care to patients. It may also be useful as a teaching
resource for qualified nurses who provide support to learners in the
clinical area and those who are returning to practice who need to be
clinically updated. The book is not intended to be a substitute for
appropriate supervision in clinical practice, and no responsibility can
be taken by the writers or publisher for any damage or injury to persons
or property.
As the emphasis is on introductory skills there are inevitable
omissions of specific procedures. Once the introductory skills have
been acquired, new skills can be learnt easily as principles for practice
will be transferable to the new situation.
Each chapter focuses on a specific area of care and related skills.
Each intervention is presented within a Nursing problem that states
the nature of the patient problem and then the goal. The currently
available evidence base is outlined and related to the problem before
the procedure is explained in simple steps. Experienced nurses tips
have been integrated into the procedures, so alerting the learner to
anticipate individual patients needs or anxieties, or to improve upon
their own performance. Each chapter concludes with key texts to supplement the procedural steps with more theory. However, the book is
vii
not a substitute for detailed study of broader nursing texts and we must
emphasize that although there is a lot of detail in some procedures,
knowledge and understanding of the full nursing curriculum should be
further pursued.
Where applicable, specific terms have been defined to aid learners in developing their own vocabulary of specialist words, and to
remind them that nursing jargon is also incomprehensible to patients.
Another language issue is gender: both nurses and patients can be
either male or female. However, to avoid the constant repetition of
phrases such as he or she throughout this book nurses are generally
referred to by using she or her, and patients by using he or him, and so
on, except where a specific patient is being discussed. This does not
imply any assumptions by the authors about typical nurses or patients,
and is merely intended to simplify the text.
Section I introduces a structured approach to aid patient assessment. Although this is not an actual procedure, it is one that is done
so automatically by experienced nurses that the knowledge and
observation skills used are often not made explicit. We have tried to
articulate many of these skills. We know from our contact with
students that the opportunity to work with experienced nurses is highly valued and very beneficial: it offers the opportunity to learn more
than just fundamental care because it provides a rich source of nursing
knowledge and skill. Development of such skills in assessment is vital
when planning, implementing and evaluating care.
Section II addresses nursing skills that are fundamental to a
patients wellbeing, recovery or comfort. These are skills that are often
delegated to students or care assistants because they apparently do not
require much technical knowledge. The delivery of safe and effective
care, using evidence-based principles, is as essential here as more technical care. It requires knowledge and theoretical understanding, and
application of principles such as infection control and patient comfort.
These are the kind of skills that make a patient feel really well nursed
or not, as the case may be and are central to providing a caring
environment for recovery and comfort.
Section III details technical skills that student nurses are frequently involved in, and outlines more detailed knowledge and procedures for
effective nursing practice. Where appropriate the interventions are
cross-referenced between chapters. For example, methods of respiratory
viii
Preface
ix
Acknowledgements
We thank our students for giving us the incentive and initial enthusiasm to write this book, and our colleagues, especially Sheila Quinn
and Brian Anthony, for providing support and encouragement.
Particular thanks are due to Middlesex University for providing
sabbatical leave for Barbara to collate and edit the contents. Thanks
also to our illustrators, Bettina Bennett and Julia Twinam, and to the
Royal Free Hospital Trust for use of their neurological observation
chart.
Last but not least, our grateful thanks to our respective longsuffering husbands, and Louise and Ralph, who provided support and
encouragement throughout the creative process.
SECTION I
Assessment
procedures
CHAPTER 1
Beginning the
assessment
process
Barbara Workman and Nora Cooper
Assessment procedures
It is important to appreciate that assessment is fundamental to all procedures that a patient may undergo. It does not happen just once but
is an ongoing process repeated at regular intervals depending on the
patients condition. The most usual time for a thorough assessment to
occur is when a patient is admitted to acute or continuing care, but
there may be other times when further detailed assessment is necessary.
Assessing a patient involves both formal and informal assessment.
Formal assessment includes the gathering of objective information
about the patients condition by interviewing him or her and obtaining answers to questions. Informal assessment includes the things that
3
you notice about a patient while you are talking to them, and may
include physical signs and subjective information such as their mood
or behaviour. The structure of these assessments will be discussed in
more detail in this chapter. Assessment of physical vital signs is also
undertaken and these are described more fully in Chapter 2. An effective assessment will ensure that a patient receives all the nursing care
that is required, and will provide a baseline from which progress can be
measured. To ensure that nursing care is planned and delivered effectively a structured approach called the nursing process is used.
The nursing process is a planned, problem-solving approach to
meeting a patients health care and nursing needs (Lippincott 2000).
It is a systematic sequence of events in which the first stage is to assess
a patients needs by the collection of objective and subjective information. The next stage is interpretation of this information, which
results in the identification of actual or potential problems that the
patient is experiencing. This can be called making a nursing diagnosis
(Lippincott 2000). Nursing goals to alleviate or prevent these problems can then be determined and problems prioritized so that the
patients immediate nursing care needs are met. These goals are used
to plan the direction and type of nursing interventions required. They
should be patient-focused, and SMART:
Specific
Measurable
Achievable
Realistic
Timebound
For example, a patient may state his problem as being extreme
breathlessness at rest. A short-term goal may be that his respiration
rate will be 2528 breaths per minute within four hours. This would
allow time for medication and nursing measures to take effect. This
goal statement fulfils the SMART requirements, and would be followed by specific nursing interventions that would contribute to
achieving the goal (see Chapter 8). There are examples of problems
and goals throughout this book, together with nursing interventions to
meet the goals.
4
problems
planning plan of care interventions to resolve or address identified
problems
implementation delivery of nursing interventions
evaluation appraisal of effectiveness of nursing interventions and
First impressions
Part of your assessment will include some of the first impressions that
you notice about the patient. As you become more experienced you
will develop these observation skills. While you are settling the patient
into the ward you will already be observing him. Springhouse (2002)
offers a mnemonic checklist SOME TEAMS to help guide you
through key patient observations:
Symmetry:
Are his face and body symmetrical? Are there any swellings of
joints or body parts?
Old:
Does he look his age? If not, can you see why?
Mental acuity:
Is he alert, confused, agitated, inattentive or responding inappropriately? Is his mood depressed, happy or lethargic?
Expression:
Does he appear ill, in pain, anxious or distressed?
Trunk:
Is he lean, wasted, stocky, obese or barrel-chested?
Extremities:
Does he have joint abnormalities, or oedema? Does he have warm
or cold hands and feet? Is his skin pale, well perfused or with a
bluish (cyanotic) tinge?
6
Appearance:
Is he clean, well kept and appropriately dressed? Has he inadequate
or excessive clothing on for the time of year? Is his skin in good condition or are there signs of rashes, bruising, dry skin or infestation?
Movement:
Are his posture, gait and coordination normal? Can he manipulate
buttons and zips with his fingers, or reach to take off his shoes?
Speech:
Is his speech relaxed, clear, strong, understandable and appropriate? Does he sound anxious, stressed, slurred or rambling?
These initial informal observations can give subtle clues about a
patients health, and are useful to reflect upon later if you think there
are changes in the patients condition, but are unable to pinpoint
exactly what those changes might be.
Assessment interview
Introductions
When you first meet the patient, introduce yourself and address him
respectfully using his proper title. This allows him to choose what he
would like to be called during his stay. If he is an inpatient, introduce
him to the other patients in his room and show him around the clinical
area so that he knows where the toilets and bath or shower rooms are,
and where to find the telephone or day room. It is often a patients first
experience of health care and he may be nervous. It is worth taking time
to put him at ease and explain who will be caring for him from the
multi-disciplinary team and how to distinguish between the uniforms of
the varying staff he is likely to meet. If English is not his first language,
you may find out at this stage that there is a language barrier, so before
you progress to the interview, see if you can find an interpreter.
a patient needs an interpreter, family members may be
TIP! Ifkeen
to help, but some private details of a patients condition
may not be suitable for a family member, particularly a child,
to interpret. For example, a woman may not find it easy to
talk about period irregularities if her son is the family translator; it may be more appropriate to use official interpreters.
7
Preparing to interview
Before interviewing the patient it is important to prepare yourself and
the patient for the assessment interview. Explain that you need to
gather some information and ensure that it is a convenient time to
interview him. The patient may like to visit the toilet, change his position, receive some pain relief, or say goodbye to relatives first. You will
need to gather the key biographical details from the medical notes so
that you can verify details of such information as date of birth, address
and contact numbers of the next of kin.
relative is the main carer it may be useful to include them
TIP! Ifin asome
of the interview, or to check some details with them
separately. However, the patient must know that all information that he gives you will be regarded as confidential and only
passed onto other health care professionals if necessary. In
some circumstances it may be particularly important that both
the carer and the patient are able to express their real feelings
and anxieties out of the hearing of the other. This should be
handled sensitively and may not happen at initial assessment.
Interview atmosphere
Provide a comfortable and quiet place in which to conduct the interview if possible, and ensure that you are not so close to the patient that
you invade his personal space, but not so far away that you have to
shout. Ensure that the patient can see you and that you are not positioned with the light behind you. Aim for a calm, unhurried and nonjudgemental atmosphere. By giving the patient time and attention he
is more likely to relax and open up and impart all the information that
you need. If you show disapproval, disgust or impatience this may block
communication (Bates and Hoekelman 2000), so you need to develop
a professional demeanour that does not make a patient feel guilty or
vulnerable about some aspects of his lifestyle for example, his alcohol or tobacco consumption.
Effective communication
Be aware that some medical jargon may prevent the patient from
understanding the questions you are asking, so use laymans language
and terms. Encourage the patient as he talks by nodding your head and
8
saying things like Go on. Help him to tell his own story by asking
questions, such as Can you tell me when this problem started?.
Nonverbal communication can tell you about the person too.
Listen carefully, and watch for body language signals. If a person is
uncomfortable about an aspect of your questions he may not make eye
contact. Some cultures, however, may consider eye contact as disrespectful or aggressive and may not meet your eyes at all during the
interview (Springhouse 2002). It is important to check that you have
understood the signals correctly. For example, if a patient is holding
himself as if in pain, you could ask a question such as You look very
uncomfortable just now, can you tell me how you are feeling? This
gives the opportunity to talk about any pain he may be feeling or any
worries he may have. Outbursts of anger, aggression, tears or rudeness
are types of nonverbal behaviour that communicate feelings such as
anxiety, insecurity and fear.
patients have to tell their stories so many times that
TIP! Some
it exhausts them, so start your assessment with the really
important things first, especially for emergency admissions.
You can fill in the gaps from the following: medical records,
letters from other health professionals, communications from
ambulance staff, accident and emergency records or friends
and relatives.
This encourages the patient to continue his story. You may use an
attentive position such as leaning forward and nodding, or a listening silence while the patient gathers his thoughts.
Reflection:
Repeating back to the patient the words that he has just said can
help him to gather his thoughts and elaborate further.
9
Confirmation:
This makes sure you are both on the right track and clears any
misconceptions.
Clarification:
You can ask the patient what he felt about a situation or events
as this may allow him to express anxiety, anger or fear.
Summarizing:
This signals the end of the interview but offers the patient the
opportunity to tell you something he may like to add.
biographical data
reason for admission
past medical history
family history
the ability to meet daily living activities
any psychosocial factors that may affect health
physical assessment of vital signs (see Chapter 2).
Additional, more focused assessment may be undertaken on any particular aspects of daily living such as nutrition (Chapter 9), breathing
(Chapter 8), continence (Chapter 10) or other specific areas depending on the patients needs and identified problems.
Recording information
Most assessment forms have specific areas that require completion in
writing, and this may follow the structure of the chosen nursing model.
10
Biographical data
Start by checking biographical details. This should include the
patients full name, address, telephone number, date of birth, age, marital status and religion. A contact number of someone who can be
called in an emergency should be included and this may be a next of
kin or, if they live some distance away, it may be a partner or spouse. It
is usual to find out who could be contacted at night, especially if the
partner or spouse is elderly and infirm. Patients may be concerned
about the implications of having to call someone in an emergency, and
so it is wise to explain that it is usual practice to ensure all contact
details are current and an emergency number is very rarely needed.
Enquiring as to whether the patient practises his stated religion
provides an opportunity for him to express whether he will want to
follow particular religious observances, such as attending a service or
saying prayers at particular times. There may be particular cultural
practices that he would wish to follow during illness, and facilities
should be made available for him to do so where possible. Further
information about cultural awareness can be followed up in the recommended further reading texts.
11
Family history
It is usual to find out whether any diseases such as coronary heart disease, some types of cancer or blood disorders, high blood pressure or
diabetes are prevalent in the family.
Nutrition
Has the reason for admission affected the patients appetite? Is he able
to shop and cook? Are there any special dietary requirements such as
diabetes or religious preferences? See Chapter 9 for more details on
nutritional assessment.
the patient is able to complete his menu so that his
TIP! Ensure
likes and dislikes are noted. If he requires a special diet,
kosher or vegetarian meal make sure it is ordered or he may
be presented with a spare meal that does not meet his particular requirements.
Elimination
What are the patients normal elimination patterns and have they
changed recently? If constipation is a problem what are the normal
measures that the patient uses to relieve it? Is urinary frequency or
incontinence a problem? More detailed assessment questions can be
found in Chapter 10.
Mobility
This includes all types of body movement: walking, moving in bed, and
manual dexterity. The amount of assistance required to keep the
patient mobile should be considered, and special equipment may be
required. For example, following assessment of mobility you may
decide that the patient will benefit from using a monkey pole to aid
moving in bed, or a walking aid when going to the toilet. It may be
appropriate to refer the patient to the physiotherapist for a fuller assessment. If a patient cannot move well they may be at risk of complications of bed-rest (see Chapter 5).
Senses
This should consider sight, hearing, smell, touch and taste.
Consideration should be given to whether the patient has hearing difficulties that require a hearing aid, or if he needs to lip-read or use sign
language. Problems with sight include the need to wear glasses, and if
13
Sleep
The patient may have had his sleep and rest disturbed by his current
problems so it is important to find out his normal sleep patterns. He may
have special night-time rituals such as taking a hot or alcoholic drink, or
medication, before bedtime. His sleep may be disturbed due to urinary
frequency, or because he cannot assume a particular position in which to
sleep because of his illness. For example, if he is breathless, he may not
be able to lie down comfortably but finds it difficult sleeping sitting up.
Occupation
A patients occupation may affect his current problem, and may be a
contributory factor, even if he is no longer in paid employment. Work
may give a patient a reason to recover from illness or assist in his rehabilitation. If a person is unemployed or has been made redundant, that
will affect his economic status and quite possibly his mental health. A
persons illness may also have an impact upon the type of work they are
able to pursue, so this information may be pertinent to preparing for
discharge.
Focused assessment
During the interview you may become aware that the patient has a particular problem with, for instance, mobility. You would then need to
explore that area in more detail, or refer the patient to an expert such
as a member of the multi-disciplinary team.
15
After assessment
Once the assessment is complete, and you have conducted the interview
and measured appropriate vital signs, you should be able to formulate a
care plan with problem statements to ensure the patient gets the care he
needs. The problem statement should be patient-centred using language
he understands and uses. For example, if the patient states he has
16
difficulty in catching his breath, this describes his problem. Nurses can
get caught up in jargon and write that the problem is dyspnoea, rather
than use the patients own words. When the problem has been stated,
goal statements are formulated. It is sometimes useful to have achievable
and measurable short- and long-term goals, or the patient can get frustrated and feel he has not progressed. The next step is to determine nursing interventions to ensure the goal is achieved, and then to evaluate
the effectiveness of the care. There are examples of nursing interventions and how to fulfil them in the following chapters.
TIP!
Many students initially find it difficult to write problem statements related to the patient. You may be inclined to use medical jargon but this does not relate to the patient. Take time to
talk to your patient and use his words. Two trained nurses
may well differ on wording on problem statements. This does
not matter: the important thing is that the patient receives
the care he needs.
Some trusts will have prescribed care plans for particular problems and
nursing interventions. These should be used where appropriate as they
save time and ensure all relevant care is documented, but patients
individual needs and preferences should be included.
Pre-assessment clinics
In many facilities, patients who are booked for an investigation or surgical procedure may be invited to attend a pre-assessment clinic visit
before their admission date. During this visit the nurse has time to prepare the patient for the admission and to explain what will happen
during the hospital stay. Routine investigations are carried out: for
example, blood tests to identify anaemia, chest x-rays to discover lung
problems, or electrocardiograms to detect any heart conditions. If any
problems are found these can then be corrected prior to admission.
When the patient is then admitted several days later, they have
had time to absorb what is going to happen and will be ready to ask
any questions they may have before they undergo surgery. Pre-assessment
visits mean that patients are admitted on the morning of their
surgery and can spend an extra night at home. Obviously this only
works for planned admissions, and is impossible for patients admitted
17
Evaluation
Evaluation determines the success of the nursing care by reviewing all
the data collected from assessment and comparing the actual outcome
of care with the expected goals (Lippincott 2000). It is like another
assessment, but is not as comprehensive as the first assessment. It will
focus just on the goals and the extent to which they have been
achieved, and the prescribed care may be adjusted if necessary. Dates
and actions of evaluation should be noted on the care plan so that
progress can be monitored.
This chapter has focused on assessing a patient by using an assessment interview and observing some physical and behavioural characteristics, thereby gathering some subjective and objective data. The
following chapter considers assessment of vital signs, which provide
significant objective data to evaluate when monitoring a patients
progress.
Further reading
Andrews MM, Boyle JS (1999) Transcultural Concepts in nursing Care, 3rd edn.
Philadelphia, PA: Lippincott.
Bates B, Hoekelman RA (2000) Guide to Physical Exam and History Taking, 6th edn.
On CD-ROM. Philadelphia, PA: Lippincott, Williams and Wilkins.
Springhouse (2002) Assessment Made Incredibly Easy, 2nd edn. Springhouse, PA:
Springhouse Publishing Company.
18
CHAPTER 2
Observations
Clare Bennett
record the oral, axillary, tympanic and rectal temperature, justifying your choice of method, and discuss normal values
measure the pulse and apex beat and discuss normal values
record the blood pressure and interpret the results
assess the level of consciousness
perform blood glucose monitoring and interpret the results.
Patient assessment
Assessment of a patients vital signs includes observations of temperature, pulse, blood pressure, respiratory rate and oxygen saturation,
blood glucose levels and level of consciousness. These observations
provide an efficient and accurate method of monitoring a patients
condition. They also enable evaluation of response to treatment and
early detection of problems.
19
Pulse rate
When the left ventricle of the heart contracts, it forces blood into the
aorta and transmits a thrust through the arterial system that can be felt
in the peripheral arteries as a pulse.
Assessment of a patients pulse provides an efficient method of
assessing the status of the heart and circulation (Perry and Potter
20
Observations
1998). There are several pulse points on the body, the most common
being the radial pulse. The radial artery is located near the radius bone
on the thumb side of the wrist. If the radial pulse is inaccessible or if it
is irregular, listening to (auscultation of) the pulse at the apex of the
heart can be used as an alternative, or a pulse can be felt at the carotid
artery which runs alongside the trachea (the windpipe) in the neck.
Factors that can affect the pulse are body temperature, haemorrhagic shock from blood or fluid loss, medications such as digoxin, or
severe head injury.
Terminology
dysrhythmia an abnormal heart rhythm
tachycardia an abnormally elevated heart rate (more than 100
beats/minute)
bradycardia an abnormally slow heart rate (less than 60 beats/
minute)
When a pulse is palpated it is important to determine the following:
rate the normal range for adults is 60100 beats/minute (Potter and
Perry 1997)
rhythm a normal pulse rhythm constitutes a regular succession of
beats. You should be able to feel if the heart rate is regular or not
amplitude the strength of the pulse beat. The pulse can feel weak,
faint and thready, or strong and bounding.
Procedure
Prepare equipment.
Wash hands.
Explain procedure to Mr Ellis.
21
Equipment
Stethoscope.
Watch with second hand or digital display.
Pens of two different colours (as per Trust policy).
Documentation sheets.
Procedure
22
Observations
Blood pressure
Monitoring blood pressure gives an indication of peripheral vascular
resistance, the effectiveness of cardiac output, and the amount of blood
volume. When measuring the blood pressure two readings are recorded. First, the systolic pressure is measured. This is the pressure that is
produced in the arteries when the left ventricle contracts, pushing
blood into the aorta. The diastolic pressure is the pressure in the arteries when the heart is in diastole (i.e. relaxes between beats).
Terminology
hypertension blood pressure raised above normal values for the
patients age and condition
hypotension blood pressure lower than normal values
23
Equipment
Stethoscope.
Sphygmomanometer with appropriately sized cuff
Pen and documentation sheets.
Procedure
Prepare equipment.
ALERT!
The bladder of the cuff should cover 80 per cent of the
circumference of the upper arm. Obese or emaciated
patients will therefore require large or small cuffs.
24
Observations
25
Table 2.1 Korotkoff sounds (adapted from OBrien and Fitzgerald 1991)
Phase I
Phase II
A brief period may follow during which the sounds soften and
acquire a swishing quality.
Auscultatory gap
Phase III
Phase IV
Phase V
Observations
Interpretation of results
Clinical management should never be based on a single blood pressure
reading (Beevers et al. 2001). The average normal blood pressure for a
young adult is 120/80 mmHg; for an older adult it is 140/90 (Potter and
Perry 1997).
Body temperature
Core body temperature is controlled by the hypothalamus. Normally,
body temperature remains relatively constant, fluctuating only 0.6C
from the average core body temperature of 36C to 38C (Perry and
Potter 1998). Temperature is affected by:
infection
prolonged exposure to heat or cold
burns
altered white cell count
certain drugs
reactions to blood products
exercise
hormonal changes
damage to the hypothalamus/brain stem.
Terminology
pyrexia
hyperpyrexia
hypothermia
afebrile
Throughout the UK, the majority of Trusts are phasing out mercury
thermometers and replacing them with electronic devices. This
reflects concerns over potential mercury spillages, reduction in crossinfection from using disposable probe covers, and more rapid readings
from electronic devices than mercury thermometers.
Electronic thermometers
The position for recording a patients temperature using an electronic
thermometer is the same as a mercury thermometer for each of the
sites. However, the manufacturers guidelines should always be followed concerning the amount of time that the probe is left in situ and
preparing, activating and cleaning the device.
28
Observations
Easily accessible.
Placement of the thermometer directly above the sublingual
artery, which is proximal to the external carotid artery, allows
changes in core temperature to be reflected promptly (Watson
1998).
Disadvantages
Equipment
Procedure
29
Glass thermometer:
It used to be argued that the main advantage of this site was that it
was safe for use in the unconscious patient and it was relatively
accurate. Although the rectal route reflects core body temperature
more accurately than the axillary site it is now rarely used, since
tympanic measurement has been found to be less expensive
(Stavem et al. 2000) and just as accurate (Cronin and Wallis 2000).
Disadvantages
30
Observations
Equipment
Procedure
Assess whether it is appropriate to use the rectal site (see advantages and disadvantages above).
Prepare equipment.
Explain the procedure to the patient.
Draw curtains around bed.
Position patient on his side, in the left lateral position if possible,
with upper legs flexed. Keep body fully covered, ensuring that anal
area can be easily exposed.
Wash hands and apply disposable gloves.
Glass thermometer:
Non-invasive.
Disadvantages
Equipment
32
Observations
Procedure
Glass thermometer:
Readily accessible.
Provides accurate core reading because of the tympanic membranes proximity to the hypothalamus and its shared blood supply
with the hypothalamus via the internal carotid arteries (Severine
and McKenzie 1997).
33
Rapid measurement.
Limited exposure to body fluids.
Disadvantages
Equipment
Procedure
Observations
Figure 2.1 Conscious level chart (copied with kind permission from Royal Free Hospital
NHS Trust).
35
The level of consciousness may be assessed by a variety of methods. Explain to the patient, whether they are conscious or unconscious,
that frequent observations are needed, both during the day and night.
It is widely believed that unconscious patients continue to hear sounds
even if they cannot respond, and if explanations are not given, they
may become restless and distressed.
All observations should be recorded according to local documentation.
Equipment
A pen torch.
Glasgow Coma Scale Chart.
Equipment for vital sign assessment, as detailed above.
Observations
ALERT!
See guidelines in pain response about testing a patients
response to pain. This procedure should be used with
caution to prevent injury.
None: the patient fails to open his eyes. This may indicate injury to
the oculomotor nerve or the brain stem.
Incomprehensible sounds: the patient responds to stimuli or spontaneously makes sounds rather than uses words.
None: no sounds at all are made regardless of stimuli. If this is due to
the presence of an endotracheal or tracheostomy tube this should
be noted.
ALERT!
Using a painful stimulus is highly contentious when
determining a patients neurological status and should
only be used with great caution (Lowry 1998).
38
Observations
Note
Figure 2.2.1.
Normal flexion.
Figure 2.2.2
Abnormal flexion.
Figure 2.2.3
Abnormal extension.
Observations
For the unconscious patient the earlier responses to painful stimuli should be documented (see Table 2.2).
Mild weakness
Severe weakness
Spastic flexion
Extension
No response
Vital signs
It is important that the patients temperature, heart rate, blood pressure
and respiratory rate are also recorded since alterations in vital signs
may indicate compression or damage within the brain stem.
nursing handover it is good practice for a set of neurologiTIP! At
cal observations to be carried out by the handover nurse with
the next nurse present to ensure consistency of results.
41
Equipment
Procedure
TIP!
Prepare equipment.
Explain procedure to Mr Ellis.
Ask Mr Ellis to wash his hands or assist him to do so.
42
Observations
in progress on the side chosen for obtaining the reading since this
may give a misleading result.
Check expiry date of testing strips and prepare glucose measurement meter according to the manufacturers instructions.
Ask Mr Ellis to hold his hand down to encourage circulation
to the fingers. Using the appropriate device, prick the side of his
fingertip.
Place the used lancet onto the injection tray for disposal.
Direct the drop of blood onto the testing strip, taking care to let
the blood drop onto the strip rather than smearing it on.
Follow the manufacturers instructions with regard to how long to
leave the blood on the strip, and to use of the meter.
Assist Mr Ellis to gently apply pressure to the site, using the cotton wool or gauze to stop bleeding and prevent bruising.
Read the result from the meter when the meter indicates that the
result is available, or, if using a manual technique, match the colour
of the strip to that given on the container after the appropriate time.
Dispose of sharps; remove gloves and wash hands.
Document observation, inform Mr Ellis of the implications of the
reading, and inform a senior colleague of the result.
ALERT!
If using a meter, it is vital to check it for accuracy before
use. Incorrect readings can cause incorrect management,
which could be fatal. It is recommended that quality
control checks are made daily and when starting a fresh
batch of test strips.
Evaluation
Were Mr Elliss observations monitored and recorded accurately? Were
any abnormalities detected and reported?
Further reading
Lowry M (1998) Trauma, emergency nursing and the Glasgow Coma Scale. Accident
and Emergency Nursing 6(3): 14348.
Watson R (1998) Controlling body temperature in adults. Nursing Standard 12(20):
4955.
44
SECTION II
Principles of
caring
45
CHAPTER 3
Infection control
Barbara Workman
Preventing transmission of
infection
Patients are at risk of infection from their own resident micro-organisms
(endogenous infection), or from external micro-organisms (exogenous
infection), which may result from transmission from infected patients,
carriers or equipment during their treatment. Health care workers
hands are also known to be the main source of transmission, and efforts
to prevent transmission of infection between patients and staff during
the course of treatment should be made (Department of Health
2001a).
A recent government report (Mayor 2000) indicated that as
many as 5 000 patients die as a result of hospital-acquired infections
47
(HAI) every year. The full impact of HAI cannot be fully calculated
since this type of infection has hidden costs, such as the following:
prolonged hospitalization
increased pain and discomfort
additional loss of earnings
increased intake of medications with potential side effects
extended disruption to the patients lifestyle and family
lengthened recovery time.
Identifiable costs to the health care trust include the use of more
equipment such as protective clothing, additional treatment time and
length of admission, and the use of more expert services such as microbiology and infection control staff (Ayliffe et al. 1999).
Nurses must ensure that good infection control practices are
maintained, always acting in a manner to promote and safe guard
the interests and well-being of patients (UKCC 1992), thereby protecting their patients from acquiring infections from any potential
source. A common problem in hospitals is the spread of Methicillinresistant Staphylococcus aureus (MRSA), a bacterium resistant to the
majority of known antibiotics, which therefore causes virulent infections in susceptible patients. This is a worldwide problem, and is
made more difficult to control as the bacteria develop different
strains over time, and emerge differently in various locations (Ayliffe
et al. 1999). The principles of preventing infection are therefore as
important as dealing with a known infection, as prevention is always
better than cure.
To be able to prevent infection spreading from one person to
another the chain of infection (May 2001) has to be broken (Figure
3.1). Taking appropriate precautions at any stage of the chain will
reduce the risks of infection spreading.
Source/reservoir
of microorganism
Route of
transmission
48
Susceptible Point of
host
entry
Infection control
prevent blood or body fluids from coming into contact with broken
skin, or mucous membranes
minimize blood or body fluid contact with intact skin
prevent sharps injuries
protect staff against Hepatitis B and C
prevent contaminated items being used between patients (Ayliffe
et al. 1999).
Routine precautions
There are various routine precautions that should always be taken:
Handwashing is essential before, between and after patient contact (Figure 3.2).
Skin: broken skin should be covered by a waterproof dressing that
acts as a barrier to micro-organisms; avoid invasive procedures if
you have chronic skin wounds.
Gloves should be worn during procedures that carry risk of contamination by blood or body fluids (see below).
Protective clothing such as aprons should be worn to reduce contamination (see below).
Mucous membranes of eyes, mouth and nose should be protected
from blood or body fluid splashes, e.g. protective spectacles may be
used during tracheal suction. If contamination occurs irrigate with
saline solution and follow steps 46 below.
Know the procedure for dealing with a needlestick injury.
Concentrate and do not rush during procedures, to prevent this
occurring.
Disposal of sharps
Sharps should be used and disposed of with extreme care:
50
Infection control
2.
3.
4.
5.
6.
Wash the area with warm water, and soap or antiseptic agent
thoroughly.
Cover with waterproof dressing.
If known note the name of the patient.
Report immediately to occupational health department if during
office hours, or designated location (e.g. Accident and Emergency)
out of hours. This will enable you to take post-exposure prophylaxis for HIV and Hepatitis B.
Notify your line manager and document the incident (UK Health
Department 1998).
Intervention
Waste
Use correct colour coding for domestic and clinical waste. The usual
colour coding in the UK is:
51
Laundry
This should also be bagged in colour-coded bags:
TIP!
ward with a fractured femur that has been fixed with a pin and
plate.
Problem: Mrs Gray is at risk of developing a hospital-acquired infection (HAI).
Goal: Mrs Gray will not develop an HAI.
Infection control
Handwashing schedule
The following schedule indicates some key times when handwashing is
obligatory.
Before:
After:
Social handwash
This is the most common form of handwash and should be used
53
Hand disinfection
Instead of soap, 35 ml of antiseptic washing solution such as
chlorhexidine, triclosan or providone iodine should be used, for a
duration of 1530 seconds, followed by thorough drying. This removes
the vast majority of transient organisms and should be used in all cases
where vulnerable patients are cared for, such as immuno-compromised
patients, those with MRSA, neonates and those in intensive care.
This method should also be used before aseptic procedures such as
urinary catheterization or wound dressing.
Surgical scrub
This may be used prior to surgery or invasive procedures: it requires
handwashing with 35 ml of antiseptic solution for up to two minutes,
and includes cleaning the fingernails. The use of an antiseptic agent
for this length of time will retain the antibacterial action for longer
afterwards. Drying should be with a sterile towel.
TIP!
Communal scrubbing brushes have been found to be a potential source of infection and therefore should not be used.
54
Infection control
2.
(1)
(3)
(2)
(4)
(6)
(5)
3.
4.
5.
6.
Turn off the taps with elbow or foot, or use a paper towel to turn
off the tap.
Dry thoroughly using disposable paper towels, working from fingers downwards, one hand at a time. Ensure all areas are dry to
prevent chapping.
Dispose of towels in waste bin as directed by local policy, e.g.
either as household rubbish (black bag) or clinical waste (yellow).
Infection control
TIP!
Gloves
If gloves are to protect the wearer then non-sterile gloves will usually
be appropriate, as they protect from heavy contamination during procedures, and prevent staffpatient and patientpatient cross-infection.
Gloves are not a substitute for handwashing: they provide a warm,
moist environment that encourages bacteria to grow, and may be penetrated by external bacteria. Furthermore, indiscriminate wearing of
gloves may cause adverse reactions and skin sensitivity. Be sure, therefore, to wear gloves at the right time and for the right reasons. For
example: gloves are not necessary when helping a patient onto a bedpan; to protect yourself from body fluids, however, wear gloves when
removing a bedpan. Sterile gloves are necessary for invasive procedures and most procedures involving immuno-compromised patients.
Check your local policies when choosing and using gloves.
TIP!
Aprons
Protective clothing is worn to reduce transmission of micro-organisms
between patients or when there is a risk that clothing or uniform may
become exposed to blood, body fluids, secretions and excretions, with
the exception of sweat (Department of Health 2001a). Plastic aprons
protect uniforms more effectively than cotton gowns. Aprons should
not be used as a substitute for a daily clean uniform, and ideally uniforms should be laundered by the Trust to ensure adequate cleaning.
Home laundering may be insufficient if the uniform has been contaminated with body fluids (Ayliffe et al. 1999).
Procedure
58
Infection control
Figure 3.4.1
Break neck tie.
Figure 3.4.2
Break waist tie.
Figure 3.4.3
Fold inwards to
discard.
Figure 3.4.13 Removing apron.
Evaluation
Mrs Gray does not acquire an HAI.
Further reading
Ayliffe GAJ, Babb JR, Taylor LJ (1999) Hospital-Acquired Infection: Principles and
Prevention, 3rd edn. Oxford: Butterworth-Heinemann.
Department of Health (2001a) Standard principles for preventing hospital-acquired
infections. Journal of Hospital Infection 47: S21S37. See also http://www.
idealibrary.com.
59
CHAPTER 4
Personal hygiene
Frances Gordon
Personal hygiene
61
Patient history
Mrs Jenny Brown has been admitted to a general medical ward via the
Accident and Emergency Department. Mrs Brown is 74 years old and
has had a stroke that has left her with a one-sided paralysis. Mrs Brown
is conscious but at present is not able to eat or drink due to her condition. She also has difficulty in communicating. Mrs Browns daughter,
Judith, has explained to the nursing staff that Mrs Brown, previous to
her stroke, was active and meticulous in her personal hygiene and
grooming. She believes that her mother will be very distressed due to
not being able to attend to her appearance. It is clear to the admitting
nurse that Judith is herself distressed by her mothers helplessness and
by her not looking as she normally does. It is noted that Mrs Brown is
perspiring, and that as she fell onto her bedroom floor during the night
she has not had her usual morning bath. At this stage, three main problems can be identified regarding Mrs Browns personal hygiene and
grooming. These are concerned with Mrs Browns inability to maintain
skin and mouth hygiene due to her present illness and the emotional
impact these factors may have on her sense of self and dignity.
Personal hygiene
assisting her to meet her hygiene needs. The assessment should include
(Penzer and Finch 2001):
A daily bed bath will be undertaken until Mrs Brown can be taken to
the bathroom for a normal bath and, due to her increased perspiration,
additional sponging will be administered as necessary.
The feeling of comfort that follows a well-executed bed bath
should not be underestimated for its potential to lift the patients
morale and to induce feelings of wellbeing. A daily wash removes skin
cell build-up and the bacteria that interact with perspiration to produce body odour. Bath time is a good opportunity for the nurse to give
private, personal time to Mrs Brown, talking with her and encouraging
her to express herself as best she can. This is also a good opportunity
for the nurse to assess the state of the patients skin and note the condition of pressure areas (see Chapter 5).
Clean linen.
Bowl of warm water (should be bowl for patients personal use).
Large bath towel, or small cotton blanket and smaller towel.
Disposable wipes.
Patients wash cloth (should not be used for perineal area).
Disposal bag.
Patients toiletries: soap or emollient, deodorant, cologne and talcum
powder if used.
Procedure
The bed is stripped down to the top sheet, and the patient made
comfortable with pillows.
64
Personal hygiene
66
Personal hygiene
Evaluation
Mrs Brown is clean and comfortable and either she or her family (if she
is unable) expresses satisfaction with her personal hygiene.
Soap or emollient.
Flannel or sponge.
Disposable cloths if required for perineal care.
67
Procedure
TIP!
TIP!
68
Personal hygiene
Assist the patient to wash, encouraging him to do as much as possible for himself.
If necessary, help the patient with hair washing, providing a cloth
to protect the patients eyes.
washing the hair with the patient in the bath, use fresh water
TIP! Iffrom
the sink and either a jug or shower connection to rinse the
hair. Check the water temperature is warm, not hot, to touch,
before pouring it over the patients head. Some elderly patients
may find it difficult to lean their head back to prevent water
flowing over their face as you rinse the hair, so provide a cloth
to protect the eyes. Wrap the hair in a towel after washing, and
make sure it is dried thoroughly to prevent the patient getting
chilled. Style it appropriately after the bath; many clinical areas
have rollers and hairdryers that can be used.
TIP!
Facilitate teeth brushing/denture cleansing and assist arrangement of hair in preferred style.
Male patients should be assisted to shave.
Help the patient back to bed or chair and ensure he is comfortable. Return the patients belongings to his locker.
Clean the bath/shower according to Trust policy and leave it tidy.
Record in the nursing notes the assessment of the patients skin
and the care that has been given. Accurate and complete records
must be kept for all aspects of the patients care. This adheres to
the legal requirement of documenting and provides a baseline of
data from which to monitor progress.
Evaluation
Has Mrs Brown had her personal hygiene needs met by having a
bath or shower? Did she have sufficient energy for the procedure or
was it too taxing? Did she manage to wash some parts of herself
independently?
TIP!
70
Personal hygiene
Oral hygiene
Mouth hygiene is an essential aspect of care for the dependent patient,
and the nurse/carer must be able to assist patients to achieve an acceptable level of oral hygiene. Assistance with oral hygiene will be needed
for patients with:
limited mobility
debilitating pain or movement restrictions
altered consciousness levels
cognitive problems, such as confusion in older people
eating or drinking difficulties, resulting in the loss of the natural
cleansing actions of saliva and potential dehydration
breathlessness, due to loss of fluid from the respiratory tract
compromised immune systems leading to increased risk of infection
radiotherapy treatments to the head and neck
oxygen therapy, which has drying effects on the oral mucosa.
Many people in the United Kingdom do not receive regular dental care
and nurses may encounter hospital patients with problems with their
teeth and gums or whose dentures no longer fit and/or are in poor condition (Evans 2001). Assessment of the mouth is therefore an important preliminary step in mouth care. Effective oral hygiene helps to
prevent infection, distress and discomfort, and, in the case of patients
such as Mrs Brown who may require speech therapy, it is a vital component of rehabilitation.
71
Patients who have natural teeth must be enabled to brush and irrigate their teeth. Brushing removes food particles, loosens plaque and
stimulates blood flow to the gums. For patients who normally wear
dentures, it is essential that they are enabled to wear them whenever
possible. This promotes dignity and comfortable eating and maintains
the shape of the mouth. However, it is not possible for some patients
to wear their dentures, for example, if they are unconscious. Patients
such as Mrs Brown will require a specialized assessment to determine
when it becomes safe for her to wear her dentures.
Equipment
72
Disposable cup.
Small torch.
Mouthwash solution made up with fresh water.
Receiver or small bowl.
Protective towel.
Tissues.
Personal hygiene
Foam sticks.
Wooden spatula.
Small-headed soft toothbrush.
Toothpaste.
Disposable gloves.
Denture pot and denture cleaning agent and brush.
Procedure
TIP!
TIP!
Inner and outer aspects of any teeth should be cleaned with the
soft toothbrush, brushing away from the gums. Gums and tongue
should be brushed very gently to prevent any injury. Foam sticks
are soft and can be used frequently to refresh the mouth, but do
not remove plaque (Burglass 1995; Moore 1995).
Toothpaste is drying and can burn vulnerable gums. It should be
carefully rinsed away. Where patients are able to rinse out their
mouths, offer the disposable cup containing fresh water or mouthwash. Where patients are unable to rinse out their mouths themselves, use a rinsed toothbrush and swab the mouth with a foam
stick. Use the tissues to wipe the mouth.
Evaluation
Does Mrs Brown have a moist, clean mouth and gums? Is her mouth
free from infection?
74
Personal hygiene
75
Evaluation
Is Mrs Brown well-presented in her own clothes? If Mrs Brown is able
to express a preference, is she satisfied with her personal grooming and
presentation? Is her daughter?
Further reading
Burglass EA (1995) Oral hygiene. British Journal of Nursing 4(9): 51619.
Evans G (2001) A rationale for oral care. Nursing Standard 15(43): 3336.
Moore J (1995) Assessment of nurse-administered hygiene. Nursing Times 91(9):
4041.
NHS Direct Online (2001) http://www.healthcareguide.nhsdirect.nhs.uk/conditions/
lice/lice.stm (accessed 26/09/01).
Penzer R, Finch M (2001) Promoting healthy skin on older people. Nursing Standard
15(34): 4652.
76
Personal hygiene
Potter AP, Perry AG (eds) (1997) Fundamentals of Nursing: Concepts, Process and
Practice, 4th edn. St Louis: Mosby.
Salter M (ed.) (1988) Altered Body Image: The Nurses Role. London: Wiley.
Turner G (1996) Oral care. Nursing Standard 10(28): 5154.
77
CHAPTER 5
Preventing the
complications of
bed-rest
Frances Gordon
and active interventions are required to reduce the risk of these complications occurring. Among the hazards of immobility are the following:
Patient history
A typical patient who would require care related to the prevention of
these complications is Mr Patel. Mr Patel is 60 years old and a retired
accountant. He has been admitted to hospital due to a sudden collapse
and is to have investigations. Mr Patel is a smoker but does not drink
alcohol. Until this incident he has been in what he describes as good
health but since his collapse feels weak and exhausted. He will be
assisted to sit out of bed and to begin mobilizing quite soon after his
79
admission to hospital but, nevertheless, his mobility will be compromised for some days. The nurse will explain to Mr Patel that he will be
asked to engage in certain activities in order to prevent complications
arising from his anticipated short-term reduction in mobility. Three
potential problems that face Mr Patel will be discussed and ways to
minimize the risks will be considered.
Exercises
A full cycle of active exercises should be undertaken by the patient at
least every hour to maintain the circulation:
Mr Patel should be encouraged not to cross his legs, have them flexed
for long periods or sit or lie with pressure under the calves, for example,
by placing a pillow beneath the calves. These activities promote
venous stasis and so predispose thrombus formation by exerting direct
pressure on the leg veins.
Compression stockings
Mr Patel should be fitted with graduated compression stockings (thrombo-embolic deterrent TED stockings). It has been shown that the use
of graduated compression stockings is effective in preventing deep vein
thrombosis in hospital patients (Amarigiri and Lees 1999). The use of
these stockings may be contraindicated in some patients with peripheral
vascular disease or diabetic neuropathy (Campbell 2001). The correct size
of stockings must be ascertained by taking accurate measurements with a
tape measure, according to the manufacturers instructions.
Hydration
Mr Patel should be adequately hydrated by offering fluids hourly (see
Chapter 7), since dehydration increases the risk of formation of deep
vein thrombosis.
Anti-coagulants
Mr Patel should receive anti-coagulant prophylaxis as prescribed. This
is usually in the form of prophylactic subcutaneous injections of
heparin, which prevents the formation of blood clots and may be prescribed for predisposed or high-risk patients.
Observations
Mr Patel should be monitored for signs of the development of deep
vein thrombosis and pulmonary embolism every x hours. Careful monitoring should detect complications early, and enable speedy instigation of treatment. Thrombus formation is often a silent process.
However, pain or tenderness in the calf, swelling and change in temperature may indicate a deep vein thrombosis, and the affected calf
may appear paler than the other. Sudden difficulty in breathing and
chest pain must be immediately reported as this could signify the medical emergency of pulmonary embolism.
The following checklist summarizes what should be monitored:
82
pyrexia
pain in the calf
swelling of the calf (measure both legs with a tape measure for
comparison)
temperature of the leg (the affected calf may appear pale and cold if a
calf vein is occluded and warm if a more superficial vein is inflamed)
chest pain and/or difficulty in breathing.
Evaluation
Mr Patel remains free from the development of deep vein thrombosis
and pulmonary embolism.
Chest infection
The second problem is associated with Mr Patel being at increased risk
of developing a chest infection due to the restrictions on his mobility
(caused by his illness and also his smoking habit). Chest infection can
occur in people with restricted mobility because proper ventilation and
drainage of respiratory secretions are inadequate, and the secretions
pool and become a focus for infection. The patient may develop what
is termed hypostatic pneumonia, a serious and in some patients lifethreatening chest infection. These risks are increased among people
who smoke. Patients who have undergone surgical operations are also
at additional risk due to several factors: anaesthetic gases may irritate
the lungs; the drugs used during and after surgery may reduce the
patients ability to breathe deeply or cough; and post-operative pain
may make the patient unwilling or fearful to cough.
Breathing exercises
Cessation of smoking
The nurse should remind Mr Patel of the importance of not smoking
in order to prevent the development of a chest infection and other
complications whilst his mobility is restricted.
Smoking increases the risk of chest infection. A sensitive
approach needs to be taken towards patients to encourage them to
abstain from smoking during hospitalization and the period of acute illness. Supportive acknowledgement of the patients smoking needs and
84
Observations
Monitor Mr Patels vital signs for evidence of infection. This ensures
that signs of infection will be detected: report elevation in temperature, pulse and respiratory rate (see Chapter 2).
Hydration
Mr Patel should be adequately hydrated. Adequate hydration reduces
the risk of sputum becoming tenacious and difficult to expectorate (see
Chapter 8).
Evaluation
Mr Patel will be discharged from hospital without having developed a
chest infection.
Pressure ulcers
The third problem arises from Mr Patels potential to develop decubitus ulcers due to his restricted mobility. Pressure ulcers, also called
decubitus ulcers or pressure sores, are localized areas of tissue damage
resulting from direct pressure for example, the weight of the patients
body lying in one position on the bed surface or from shearing forces
that cause mechanical damage between skin and bone and result in tissue ischaemia (Pedley 1999). Pressure ulcers usually occur over bony
prominences such as the sacrum, knees and hips (NHS Centre for
Reviews and Dissemination 1995). Among the patients at high risk for
developing pressure ulcers are the following:
85
to restricted mobility.
Goal: Mr Patels pressure areas will remain intact.
mobility
nutritional status
continence problems
the patients general physical condition.
Maintaining mobility
Explain to Mr Patel the importance of moving around the bed as much
as possible. Assist Mr Patel to change position to relieve pressure on
pressure areas every two hours using recommended manual handling
techniques. Relief of pressure is essential to prevent tissue damage, and
appropriate manual handling techniques are essential to prevent friction and shear injury.
Encouraging the patient to avoid remaining in one position for long
periods helps to prevent pressure on the bony prominences. However,
Mr Patel should be warned about movements that may involve a shearing action on the bed surface. Shearing movements involve friction,
such as dragging the skin over the bed surface rather than lifting his skin
above the surface of the bed or chair before moving, or using a sliding
sheet when helping Mr Patel change position. Pressure sores can be prevented by good bed-making, which smooths creases in bed linen or the
patients garments. Damp sheets resulting from perspiration or urine
should be changed promptly. Make sure that crumbs or other small
objects (including catheters or drainage tubes) do not get trapped against
the patients skin and cause pressure. Also, make sure that the top covers are not too tight and restricting to the patients movements.
Mr Patel to use television or radio timings as reminders
TIP! Advise
for him to change his position on a regular basis.
Skin inspection
Inspect the skin at each position change and record condition of pressure areas. Early detection of skin changes that may indicate pressure
problems is essential. These include fixed red marks that do not fade
87
(erythema): blanching if gentle pressure is applied indicates that circulation is still intact; however, if the area of redness does not blanch,
disruption to the microcirculation is evident. Erythema is more difficult to detect on darker skins such as Mr Patels, so attention should be
paid to swelling, change in skin temperature, and discomfort. It is
important that an accurate record of the patients skin condition is
maintained. This ensures that interventions are appropriately implemented according to the patients condition.
Nutrition
Ensure that Mr Patels nutritional status is adequate and that he
remains hydrated. Poor nutrition and inadequate hydration are factors
that increase the risk of pressure ulcer formation (see Chapter 9).
Skin hygiene
Ensure that Mr Patels skin hygiene is maintained to a high standard.
Skin breakdown is more likely in patients who are incontinent, due to
the presence of moisture-containing bacteria that can cause skin maceration. The maintenance of skin hygiene is therefore very important
in the prevention of pressure ulcers, but care must be taken not to
88
Evaluation
Mr Patel will be discharged from hospital with his skin free from the
development of pressure ulcers.
Further reading
Long BC, Phipps WJ, Cassmeyer VL (1995) Adult Nursing: A Nursing Process
Approach. London: Mosby.
NHS Centre for Reviews and Dissemination (1995) The Prevention and Treatment of
Pressure Sores. York: NHS CRD.
89
SECTION III
91
CHAPTER 6
Drug administration
Barbara Workman
state and apply the five Rights (5 Rs) of safe drug administration
outline the AF points for safe practice
calculate a common drug dose
undertake safe administration of oral, rectal, parenteral and eye
medications under supervision.
Administering medication
The administration of medications is controlled by three Acts of
Parliament the Medicines Act (1968), the Misuse of Drugs Act
(1971) and the Poisons Act (1972) and a Statutory Instrument the
Misuse of Drugs Regulations (1985). These provide the framework
within which medicines are stored, transported, prescribed, recorded,
dispensed and administered. The British National Formulary (BNF)
provides a summary of the key legal issues for health care practitioners,
which is beyond the scope of this chapter but can be referred to for
93
further guidance. You should also familiarize yourself with local policies
and guidelines, which should be available in your workplace for reference.
Advances in treatment and drug therapy progress rapidly in nursing and medicine, and as professional research and knowledge expands
so must your repertoire of knowledge, to underpin safe practice. The
guidelines for safe practice are outlined in this chapter but it is the
responsibility of individual practitioners check the product information of each drug during its administration, in order to verify the dose,
route, time, method of administration and contraindications. When
administering the drug you must ensure that proper procedures have
been followed.
Administering drugs by different routes and for various purposes is
a common activity in nursing. The UKCC Guidelines for the
Administration of Medicines emphasize that in administering any
medication, or assisting or overseeing any self administration of medication, you must exercise your professional judgement and apply your
knowledge and skill in the given situation (2000: 4). This means that
you should have:
Right patient
Right drug
Right dose
Right time
Right route.
Right patient
Check the identity of the patient with his identification band, using
hospital number or date of birth as additional verification. If patients
94
Drug administration
Right drug
Drug names can be complex, and have similarities between names.
Check for clearly written prescriptions, matching the name on the
medication container. In hospital, drugs are prescribed by their generic names, and patients may be confused and think that they are having
a new medication. If in doubt, consult the BNF for the generic and
trade name of the drug.
Check three times during the procedure:
Right dose
This should be clearly written on the prescription sheet. If the dose is
very small, then micrograms should be written out in full (BNF).
Calculate the dose carefully (page 99) and check to see if there is a
drug with the same name but dispensed in different strengths.
need to calculate the dose, make sure you know what
TIP! Iftheyou
usual dose is likely to be so that if your calculations result
in an unusual number, like six tablets rather than two, you are
alerted to check it again, preferably with another person.
Right time
Most drugs are designed to be given with an interval of several hours
apart to provide a consistent therapeutic blood level. If given haphazardly, then the medication will be less effective or may cause the
patient to develop unwanted side effects. Therefore, it is essential to
give doses at prescribed intervals and to record the actual time of
administration.
95
Right route
Medications are given licences for specific routes of administration. It
is possible to give medication by the wrong route, for example, an
intramuscular injection may be given intravenously if sited in the
wrong place.
Accurate prescription
Best information
Correct dispensing
Deliberation before administration
Effective systems
Fail-safe policies.
Accurate prescription
Prescription sheets should be clearly written, and should include the
patients name and hospital number, weight and allergies or state no
allergies known. It should include the doctors signature, and the date
of commencement or discontinuation of medication. The generic
name of the prescribed drug should be used. Abbreviations should not
be used for micrograms or nanograms. Doses should be in specific metric measures rather than number of tablets, for example, paracetamol
1 g rather than paracetamol 2 tabs. Following administration, all documentation should be completed accurately and legibly, and using the
accepted local abbreviations, for example if the patient is nil by
mouth and cannot take his medicine, then that should be recorded
on the prescription sheet.
you withhold a drug for any reason, make sure that the
TIP! Ifmedical
staff know. It may need to be given by another route,
or its suitability for that patient may need to be reviewed.
Best information
Your patient has a right to ask you about his medication, and you
should be able to explain what the medication is for. The patient may
96
Drug administration
not wish to take his medication without knowing how it may affect
him. A nurses role is to teach the patient about his medications:
Correct dispensing
Pharmacists dispense many medications daily and may occasionally
make errors. The nurse should ensure that the dispensed drug is correct
against the prescribed drug. This is particularly necessary when the
drug has been prepared in the pharmacy and is ready for administration
without further preparation in the clinical area. The dose, labelling
and prescription should be checked for any peculiarities before administration. If you are unfamiliar with the dose or drug do not assume that
it is right. Confirm the dose rather than cause a severe error.
Effective systems
Studies have demonstrated that if systems and procedures are not followed, there is an increased likelihood of medication errors (OShea
1999). A counter check against error can be provided by the use of a
structured routine, such as this:
Such systems should alert you to danger signals that may lead to an
error, thereby adding security to the proceedings.
Fail-safe policies
The Trust that you work for should have clear policies concerning the
mechanisms, supervision and training for drug administration, and for
reporting near misses. These should be followed not only to prevent
error and subsequent litigation but also because such policies encourage good practice. However, there may be changes in knowledge and
clinical practice that become accepted practice within the Trust, but
are not recorded immediately within Policies (Colleran Cook 1999).
You may need to ensure that your Manager is aware of these changes
in practice to ensure that the local Policies reflect actual current practice. For example, to reduce errors and spread the workload, your unit
may decide that night staff will not give drugs in the morning but wait
for the day staff to do it. Local policy may need to take that change into
account so that nursing and medical staff are all aware of it.
To reduce potential errors you should only administer drugs to
TIP! your
group of patients, so that you are familiar with their particular needs. Also, consider the timing of doses. If a patient
needs to take some medication before and some after his
meal, dont be tempted to give it to him all at once, relying on
98
Drug administration
Converting measurements
To change kilograms to grams, multiply by 1 000:
e.g. 5 kg 1 000 = 5 000 g
To change grams to milligrams, multiply by 1 000:
e.g. 5 g 1 000 = 5 000 mg
To change milligrams to micrograms, multiply by 1 000:
e.g. 0.625 mg 1 000 = 625 micrograms
To change milligrams to grams, divide by 1 000:
e.g. 500 mg 1 000 = 0.5 g
To change micrograms to milligrams, divide by 1 000:
e.g. 250 mcg 1 000 = 0.25 mg
total volume: 5 ml =
30
5 = 2.5 ml required
60
It is important to ensure that the units are consistent in the calculation, i.e. either all milligrams or all micrograms. If the numbers are not
all converted to the same units, drug errors up to 1 000 times too big or
too small may occur.
Example: a patient is prescribed Nifedipine 0.06 g. Tablets of Nifedipine are 20 mg strength. How many should be given?
What you want: 0.06 g
What youve got: 20 mg
First the decimal 0.06 g must be converted into a whole number, consistent with the drug as dispensed:
0.06 g 1000 = 60 mg
The formula can then be used:
60 mg
20 mg
1 = 3 tablets
100
Drug administration
times.
Goal: Mr Jenkins will be assisted to take his oral medication when
necessary.
Oral medication
The oral route is the safest, most convenient and least expensive
route for medication delivery. Oral drugs are available in many forms
of tablets, capsules or granules, or liquids such as syrups, or suspensions. Most are suitable to be swallowed without further preparation,
but some may need dissolving or mixing before consumption. If
patients cannot swallow their medication because it is in an inappropriate preparation, such as a large tablet, advice from the pharmacist
should be sought to see if an alternative preparation is available.
Planning
If several patients are to receive their medications at a set time, it is an
acceptable practice to use a trolley stocked with all the equipment
required (Williams 1996). Ideally this should be the group of patients
that you are currently caring for.
This equipment should include:
101
3.
4.
5.
6.
102
Drug administration
Figure 6.1
Decanting tablets
into container lid.
7.
Tip the dose into the pot. If measuring liquid: ensure the lid is on
firmly and then shake the bottle to ensure the contents are well
mixed. Put the pot on a level surface, pour the liquid into it, turning the bottle label away so that it does not get dripped on and
obscured by medicine. Pour to the required level (Figure 6.2).
8.
9.
Figure 6.2
Measuring liquid
dose.
103
Drug administration
Figure 6.3
Sublingual
tablet.
Figure 6.4
Buccal tablet.
occurring. The patient should not drink until after the tablet has dissolved. Therefore, all other medication should be taken first.
checking sublingual or buccal tablets, put them into a
TIP! When
separate pot from the other tablets so that they are easily
identifiable and are not swallowed by mistake.
Evaluation
Did Mr Jenkins manage to take his oral medication? Do you need to
find alternative preparations?
routes.
105
choice of preparation
timing
drug interaction with enteral feeds
administration via the tube.
Choice of preparation
Ideally, the medication should be in liquid form. Should a liquid preparation not be available, some tablets will dissolve or the pharmacy
may be able to prepare a suspension. Capsules may be aspirated by
needle and syringe or dissolved in water, and the liquid administered.
Granular capsules may be opened and mixed with water. Tablets may
be crushed in a pestle and mortar or between two spoons. All tablet
residues should be mixed with water and drawn up into a syringe for
administration to ensure the correct dose is given.
ALERT!
Enteric-coated medications, modified-release preparations
and some hormones and cytotoxic drugs should not be
crushed as it changes the chemical actions of the drugs. It
is imperative to check with the pharmacist the preferred
way of preparing each of these types of medication to
ensure that the drug is given correctly.
Timing
If medication should be taken on an empty stomach, it is advisable to
stop the feed for 30 minutes before administration, and resume the
feed 30 minutes afterwards. The exception to this is Phenytoin
(Naysmith and Nicholson 1998), which requires a break from
106
Drug administration
feeding for two hours before and after the feed to allow full
absorption of the drug.
Administration procedure
Equipment
Procedure
The procedure described above for oral medication (page 102) for
administering a drug should be followed, but with the following additional considerations:
1.
2.
3.
4.
5.
6.
Attach the bladder syringe or the larger luer lock syringe without
the piston attachment to the NG tube. This will act as a funnel.
Hold the syringe slightly above Mrs Eastons nose height to prevent backflow.
7.
Slowly pour the medication from the small syringe or cup into the
barrel of the larger syringe, ensuring that the large syringe is held
upright, and unclamp the NG tube. Raise the tube to speed the
flow (Figure 6.6.1) or lower the height of the syringe to slow the
flow (Figure 6.6.2). To prevent air from entering the patients
stomach, add fluid to the larger syringe before it empties completely. If resistance is felt or the tube is blocked, do not force the
flow. Check the position of the NG tube by aspiration, and
Figure 6.5
Kinking
nasogastric tube.
108
Drug administration
8.
9.
10.
11.
12.
13.
Controlled drugs
These are drugs whose prescription and use is governed by the Misuse
of Drugs Act (1971), as they are potentially addictive. In the hospital
setting, controlled drugs (CDs) are ordered by a registered nurse, in a
duplicated order book, which must be signed when receiving drugs
Figure 6.6.1
Figure 6.6.2
110
Drug administration
Both persons should go to the bedside, where the patients identity should be confirmed and the prescription dose, time and route
should be checked again.
Administer the medication by the prescribed route, and document
this on the prescription sheet and in the controlled drug record.
The patients age: elderly patients may have muscle wasting which
may limit the choice of site, and babies who are not yet walking
may have underdeveloped muscles, particularly in the buttocks.
General physical status: emaciated or cachectic (extremely debilitated) patients may also have muscle wasting or poor perfusion
and skin condition. Oedematous limbs will not absorb medication
as effectively as those with good perfusion.
The drug therapy: the amount to be given, and the frequency and
consistency of medication will influence the choice of location.
For example, a depot injection (long-term slow-release action)
will require a deep muscle, to allow sufficient slow absorption over
a period of time.
Dorso-gluteal site
The patient should lie either on their side with knees slightly bent, or
prone with toes pointing inwards (Figure 6.8). An imaginary line is
drawn across from the cleft of the buttock to the greater trochanter of
the femur. Then a vertical line is drawn midway across the first line,
and the outer quadrant is identified. This quadrant is then divided into
four quadrants: the desired location is the upper outer quadrant
(Campbell 1995). The aim is to access the gluteus maximus muscle,
and to avoid the sciatic nerve and gluteal artery. The typical absorption volume is 24 ml.
Figure 6.7
Deltoid site.
112
Drug administration
Figure 6.8
Dorso-gluteal
site.
Ventro-gluteal site
The patient can lie on either side with knees slightly flexed. Place the
palm of your right hand onto the left greater trochanter (or right hand
onto left hip), and extend the index finger towards the superior iliac
crest. If you have small hands, start with the palm of the hand on
the greater trochanter, and slide the hand up until the tip of the index
finger touches the iliac crest (Covington and Trattler 1997). Stretch
out middle finger to form a V and the injection should be located into
the centre of the V. This will enter the gluteus medius and minimus
muscles (Figure 6.9). There have been very few complications documented from the accurate use of this site (Beyea and Nicholl 1995).
The typical absorption volume is 24 ml.
Figure 6.9
Ventro-gluteal
site.
113
Figure 6.10
Proximity of DG and
VG sites to each
other.
Figure 6.11.1
Vastus lateralis
site.
Figure 6.11.2
Rector femoris
site.
Figure 6.11.12 Locating vastus lateralis and rector femoris sites.
114
Drug administration
Figure 6.12
Bunched-up
muscle.
Figure 6.13
Inserting air into
vial.
Withdraw required amount into the syringe. Remove the vial, and
holding the syringe with the needle uppermost, tap the syringe firmly to
encourage air bubbles to rise to the top to be expelled. Larger syringes
may have the connection on the side, rather than the middle of the
syringe. To aid the air to rise to the top, tip the syringe to a slight angle
so that the air collects under the connection, and keep it at that angle
until all the air is expelled (Figure 6.15). This ensures an accurate dose.
116
Drug administration
Figure 6.14
V-shape to draw
up injection.
Figure 6.15
Expelling air
from syringe.
Change the needle. This ensures that the injection is given with a
clean, dry, sharp needle thus reducing pain (Beyea and Nicholl 1995),
and prevents a possible sharps injury resulting from transporting the
injection to the patient.
the amount of dose in the syringe after you have
TIP! Recheck
expelled the air to make sure that you still have the right
amount in the syringe and did not lose any when changing the
needle. If the dose is very small do not expel the air until after
you have changed the needle so that there is minimum
wastage.
Procedure
118
Drug administration
Z track technique
The Z track technique was originally used for drugs that stain the skin
or are particularly irritant. Beyea and Nicholl (1995) recommend it as
a method to reduce pain and leakage from intramuscular sites.
Following location of site use the thumb to pull the skin about
3 cm to one side (Figure 6.16).
Insert the needle at 90, release the thumb.
Administer the injection as above.
Return the thumb to retract the skin, and then remove the needle.
Remove thumb and allow skin to return to usual position.
2.
4.
Figure 6.16
Z track
technique.
119
5.
6.
7.
8.
9.
overused.
the needle at an angle of 90 to prevent shearing and tissue displacement (Katsma and Smith 1997).
10. Inject medication steadily and slowly about 1 ml per 10
seconds to allow the muscle to accommodate the fluid.
11. Wait 10 seconds after completion of the injection to allow
diffusion through the muscle. Then remove the needle at
the same angle as it entered.
12. Apply gentle pressure but to prevent local tissue irritation
do not massage the site afterwards.
Evaluation
Did Mrs Easton receive her medication by the most effective route?
Patient history: Mrs Bell is a young woman who has just been diag-
subcutaneously.
Goal: Mrs Bell will be able to safely administer her insulin subcutaneously.
Drug administration
Figure 6.17
Subcutaneous
injection sites.
Figure 6.18
Drawing up from
a multi-dose vial.
122
Drug administration
Figure 6.19
One-handed
resheathing of
needle.
Procedure
The first stages of the procedure are the same as those described for oral
drug administration (page 102).
WARNING!
If not using insulin equipment for SC injection the needle is
longer and therefore needle entry should be at 45.
Evaluation
Mrs Bell is able to administer subcutaneous insulin correctly.
colon.
Goal: Mr Elland will safely receive rectal medication to relieve discomfort.
Rectal medication
Rectal medication bypasses the upper gastro-intestinal tract, avoiding
liver metabolism and therefore working quickly. It is suitable for
patients who are unconscious, unable to swallow or are vomiting.
Drugs given by suppository or enema can produce a local effect e.g.
to relieve constipation or treat local inflammation or can work systemically e.g. to provide pain relief.
Before administering medications rectally you should check the
anal area to ensure there are no signs of rectal bleeding, skin tags,
recent anorectal surgery, undiagnosed abdominal pain or paralytic ileus
(Addison et al. 2000), as the procedure may aggravate these conditions. An unhurried and gentle approach should be taken to administering medication rectally, because the procedure can induce vagal
124
Drug administration
Tray.
Prescribed suppositories as per prescription or by group protocol.
Disposable gloves and apron.
Lubricant: either water for glycerine suppositories, or water-based
lubricant.
Tissues or gauze swabs.
Protective bed cover such as incontinence pad.
Waste disposal bag.
Easy access to toilet, bedpan or commode.
Procedure
Prepare to administer medications as described for oral administration of drugs (page 102).
Wash hands and prepare equipment.
Prepare Mr Elland. Ask Mr Elland to empty his bladder to reduce
pelvic discomfort. If the medication is for systemic effect, ask him
to empty his bowel if he is able. This will ensure an empty rectum
and facilitate absorption. He should give his verbal consent to
treatment. Encourage Mr Elland to relax as much as possible by
providing privacy and ensuring that interruptions are prevented.
Position Mr Elland on his left side, so allowing the direction of the
suppository to follow the natural direction of the GI tract. Bend
his knees slightly to aid comfort and ease access to the anus. Cover
him with a blanket to maintain dignity and warmth.
Protect the bed by placing the incontinence pad under his buttocks. This will reduce Mr Ellands embarrassment if there is any
discharge or leakage.
Put on gloves.
Open suppositories and place on gauze or tissue. Lubricate as advised
on pack. Glycerine suppositories may be lubricated with water.
With your left hand, lift the upper buttock and observe the anal
area for evidence of local tissue damage. Encourage deep slow
125
Figure 6.20.2
Blunt end of
suppository inserted
first for systemic
effect
Drug administration
Gentle pressure on the anal area with a gauze or tissue pad will
reduce the desire for immediate defaecation. Encourage Mr Elland
to retain the suppository for as long as possible (at least 20 minutes) for it to be effective, and to rest on his side for at least five
minutes to aid retention.
Clean perineal area with tissues.
Dispose of all waste, removing gloves by turning inside out to
prevent cross-contamination.
Wash hands.
Record administration on the prescription sheet and document
the outcome.
Procedure
Prepare to administer medications as described for oral administration of drugs (page 102).
Wash hands and prepare equipment.
At the bedside remove outer packaging from the enema if necessary and place in warm water to raise it to room temperature to
reduce shock and bowel spasms. Retention enemas are usually
200 ml or less to promote retention (Addison et al. 2000).
Prepare Mr Elland. Ask Mr Elland to empty his bladder to reduce
pelvic discomfort. If the medication is for systemic effect, ask him
to empty his bowel if he is able, to ensure an empty rectum and
127
128
Drug administration
Evaluation
Did Mr Elland receive his suppository or enema without discomfort?
What was the effect of the medication?
Ophthalmic medication
Ophthalmic medication is usually applied topically, the most common
methods being eye drops or ointment. These may be used for diagnostic purposes such as dilating the pupil prior to examination; anaesthetizing the eye prior to treatment, or for treatment of eye conditions
such as glaucoma or infection.
Heywood Jones (1995) recommends that administration of ophthalmic medication follows these principles:
129
Figure 6.21
Eye drops
directed into
lower eyelid.
130
When clearing discharge from the eye or wiping away excess medication, do not use dry cotton-wool balls as fibres may get into the
eye and damage the cornea.
Always work from the inner canthus (nose side) outwards to edge
of eye when applying ointment or swabbing eye to reduce infection risk.
Medication containers should not touch the eye during administration as they may become contaminated or damage the eye.
Once an eye medication has been opened, record the starting date
on the container and discard after two weeks.
If both eyes are to be treated but only one is discharging, treat the
cleaner eye first to prevent cross-infection. Wash hands between eyes.
Drug administration
Procedure
Figure 6.22
Hand positions
to administer
eye drops.
132
Tell Mrs Paur to look upwards, so that the cornea is raised away
from the site of medication delivery.
Deliver the required number of drops into the lower lid area
nearer the outer edge to reduce drainage from the nasal tear duct.
If more than one type of drug is to be administered, allow several
minutes to elapse between different medications.
If administering ointment, squeeze a length of ointment along the
lower lid from the inner canthus to the outer, squeezing out additional ointment as required. To break the flow of ointment, twist
the tube upwards, and stop pressing the tube. Be careful not to
touch any part of the eye or eyelid as it will cause Mrs Paur to
blink and interrupt the application flow.
Remove hands and allow Mrs Paur to blink gently two or three
times to disperse the medication, but do not let her squeeze her
eyes.
Dry excess moisture with tissue or sterile gauze.
Leave Mrs Paur in a comfortable position. Advise her that her
vision may be briefly impaired while her eyes respond to the
medication.
Wash hands and dispose of all waste.
Document on the prescription sheet. Record in the nursing notes
any observations regarding the state of the treated eye, such as
redness, inflammation or amount of discharge.
Drug administration
Evaluation
Were Mrs Paurs eye drops given effectively?
Further reading
Beyea SC, Nicholl LH (1995) Administration of medications via the intramuscular
route: an integrative review of the literature and research-based protocol for the
procedure. Applied Nursing Research 5(1): 2333.
British National Formulary. London: British Medical Association and British
Pharmaceutical Society.
Covington TP, Trattler MR (1997) Learn how to zero in on the safest site for an IM
injection. Nursing (January): 6263.
Naysmith MR, Nicholson J (1998) Nasogastric drug administration. Professional Nurse
13(7): 42427.
Rodger MA, King L (2000) Drawing up and administering intramuscular injections: a
review of the literature. Journal of Advanced Nursing 31(3): 57482.
Workman BA (1999) Safe injection techniques. Nursing Standard 13(39): 4753.
UKCC (2000) Guidelines for the Administration of Medications. London: UKCC.
133
CHAPTER 7
Maintaining fluid
balance
Barbara Workman
Accurate measurement of a patients fluid intake and output will identify those patients at risk of becoming dehydrated or overhydrated.
Particularly vulnerable patients are:
the elderly, who may have lost their thirst stimulus and neglect to
drink
the confused or neurologically disordered, who may fail to respond
to thirst
those whose conditions are deteriorating, e.g. with renal or cardiac failure
post-operative patients
135
in hot weather
with a pyrexia (high temperature)
if a urinary catheter is in situ
if constipated
if there is fluid loss from the gastro-intestinal tract, such as diarrhoea, vomiting, or nasogastric or wound drainage.
Patient history
Mrs May is a 79-year-old lady who has been admitted following a fall
at home. Her daughter normally drops in to see her most days, but had
been away for the weekend, and found Mrs May on the floor when she
came home. Her daughter says that Mrs May is very independent but
has become increasingly forgetful recently, and would sometimes forget
when she last had a meal. Mrs May has facial bruising and a possible
head injury so has been admitted for observation.
136
Ensure the drink is placed within the reach of Mrs May, and that she
can pick up and hold it and is in a safe and comfortable position to
consume it. Offer a feeding beaker if necessary. Assist drinking if the
fluid is very hot and there is a danger of scalding.
Offer a wide range of fluids to improve incentive to drink.
Evaluation
Mrs May is no longer dehydrated, and is able to maintain a satisfactory
fluid intake.
138
Inform Mrs May that you are monitoring all her fluid intake and
output to gain her cooperation.
If Mrs May is able to use the toilet, ask if she is able to pass water
directly into the measuring jug. She may find it more acceptable
to pass water into a bedpan on the toilet, or use a bedpan or commode. Dispose of toilet tissue in clinical waste bag.
Wear clean gloves and apron and use an individual measuring jug
when measuring urine to prevent cross-infection (Ayliffe et al.
1999).
Empty fluid contents of bedpan or commode into jug. Some fluid
may be lost when the toilet tissue is discarded.
In addition all fluid excreta should be monitored. Vomit should be
poured into the jug to be measured. If measuring gastric aspirate,
the nasogastric tube should be fully aspirated and the contents
poured from the bladder syringe into the measuring jug. When no
more fluid can be aspirated the amount may be measured. If small
amounts of any fluid, particularly urine, are passed, accurate measurement in a jug will not be possible under 50 ml. A bladder
syringe or calibrated urinometer should be used to ensure accurate
measurement of small quantities.
Record on fluid balance chart (see example below), and report any
abnormalities to senior staff.
Evaluation
Mrs Mays urine output has returned to and is maintained at 1.5 litres a day.
Oral
OUTPUT
IV
Urine
Vomit
Drainage
Other
Balance
(hours)
01.00
1 litre
D/Saline
start
02.00
03.00
04.00
350
05.00
06.00
07.00
08.00
tea 100
D/Saline
juice 60
1 000 ml
200
550
+1160
given. 5%
= +610
Dext 1
litre start
09.00
10.00
coffee
60 ml
11.00
140
250
25 drain
removed
Oral
12.00
soup 100
OUTPUT
IV
Urine
5% Dext
finish 1 000
ml given.
500 ml
0.9% Saline
start
250
Vomit
Drainage
Other
Balance
13.00
14.00
15.00
16.00
tea 200
+2 520
1 075
= +1 445
17.00
18.00
tea 100
300
19.00
20.00
21.00
22.00
water 100
23.00
225
24.00
water 100
0.9% Saline
400 ml
given. IVI
discontinued
Total
820
2 400
Balance +3 220
+3220
1600
= +1 620
1 575
1 600
Nil
25
Nil
+1620
Fluid overload
It is possible to overhydrate a patient, particularly when administering
intravenous fluids. The patient may present with the following symptoms (Perry and Potter 1997; Edwards 2000):
141
Sodium chloride can be infused in other strengths to correct electrolyte imbalance, e.g. 1.8% or 3%. These concentrations are hypertonic and so draw fluid from the cells into the plasma and interstitial
fluid compartments, thus increasing the fluid in circulation.
5% dextrose in water
This isotonic fluid provides fluid replacement without disturbing the
electrolyte balance and provides energy up to 170 calories in 1 litre
(Hand 2001). Stronger concentrations of dextrose such as 10% or 20%
may be used to provide calorie intake for patients who are temporarily
unable to eat. Dextrose infusions, especially when containing potassium, are acidic and may irritate a patients veins causing phlebitis after
several days, use.
Other substances may be used to expand intravascular volume, such as:
Procedure
Take equipment to the bedside and position the patient comfortably with easy access to the non-dominant arm. This arm should
be chosen in preference, so that Mr Elliot may use his dominant
arm and maintain some independence during treatment.
Check prescribed fluid against prescription sheet and follow the five
Rs for right drug administration Right patient, Right drug (fluid),
Right route, Right time, and Right dose.
Wash hands.
Open the outer wrapper of the prescribed fluid. Check the container for cracks, leaks or breakage in sterility; expiry date; and
check that the fluid is clear any discolouration, particles or cloudiness indicates contamination.
Invert the bag several times gently but do not shake to ensure the
solution is well mixed. This is particularly important if potassium or
other drugs have been added to prevent layers forming (Metheny
1990).
Open the administration set pack and close the clamp. See Figure
7.1 for different types of clamps.
Place the bag on a flat surface and break the protective cap off the port.
Remove the protective cap from the administration set spike.
Holding the connection port firmly in one hand, insert the spike
into the port with the other hand, ensuring that the connections do
not touch anything (Figure 7.2).
Hang the bag on the IV pole and squeeze the administration set
chamber to half full.
Open the roller clamp and allow the fluid to run through the
administration set into a receiver until it emerges at the end (Figure
7.3). Ensure all air bubbles are removed. Clip the end of the tubing
of the administration set into the roller clamp to prevent it from
being contaminated.
145
Slide clamp.
Figure 7.2
Connecting IV
bag and
administration
set aseptically.
Figure 7.3
Running
through
administration
set.
146
cutting with scissors that have been cleaned using an alcohol wipe
(Workman 1999), and dressing the site with sterile gauze. (See
Securing a cannula, page 150.) However, the usual, and increasingly preferred, method is to use a specific IV dressing which is
semi-permeable to allow the site to breathe and remain dry without admitting micro-organisms. It should be applied to clean dry
skin, maintaining aseptic technique and not touching the sterile
surface. The dressing is applied directly over the insertion site and
Figure 7.4.1
Place strip under
cannula wings.
Figure 7.4.2
Secure each
wing parallel
to cannula.
Figure 7.4.3
Tuck strip arond
cannula hub.
Figure 7.5
Transparent
dressing to
cannula and
securing IV set
to arm.
tucked around the hub of the cannula to ensure a firm seal, and
prevent movement of the cannula (Figure 7.5).
Secure the administration set by taping the tubing to Mr Elliots
arm (Figure 7.5) to prevent pulling on the cannula site. Bandages
and/or splints should only be used in exceptional circumstances,
for example, if the patient is a child or confused. If secured too
tightly they can prevent the infusion from running satisfactorily,
prevent regular observation of the limb, and cause stiffness and
discomfort.
Commence the infusion at the prescribed rate. Check again within the hour that the infusion is running as previously set.
Label the administration set with the date and time of commencement, and your initials.
Make Mr Elliot comfortable, and ensure that he has all he requires,
including the call bell.
Dispose of all equipment and wash hands.
In the nursing notes, document: the site and size of cannula; time
and date of commencement of infusion and set rate on the fluid
balance chart; and the batch number, start date, time and signatures of administering staff on the prescription sheet.
Securing a cannula
The entry site of the cannula should not come into contact with the
tape as it has been found to predispose to infection. Use a clean or new
roll of tape, and cut with scissors that have been cleaned, or are sterile.
Using the H method, as illustrated, for cannulas with wings will secure
149
the cannula firmly and be easy to remove, and keep the tape well away
from the cannula site. This method should only be used if the patient is
allergic to a transparent dressing, or if there are none available.
Procedure
150
Management of an IV infusion
Intervention: regulation of flow rate
The flow rate of an infusion is determined by the amount of fluid to be
given over a prescribed time. Fluid rate can be controlled manually by
using a slide or roller clamp, which can be adjusted to deliver fluid at
a number of drops per minute by a gravity administration set. This
method will deliver approximate amounts, and therefore will not be
suitable for all IV fluids. Fluids that require an exact delivery rate
should be given by a syringe driver, electronic pump or mechanical
pump. It is important to deliver fluids as prescribed to prevent fluid
overload, and to ensure accurate drug doses.
To accurately deliver fluids the correct administration set should
be selected. Check the label on the packaging to determine how many
drops per minute it will deliver and the compatible type of electronic
infusion device:
standard administration set = 20 drops per ml for aqueous solutions: this set may be used with or without a compatible electronic device
blood administration set = 15 drops per ml: this has an integral
filter system but particular treatments may require additional
filtration
paediatric administration set (burette) = 60 drops per ml: a burette
may also be used for adults when delivering some intravenous
drugs or small amounts of fluid.
151
drops per ml
60 (minutes)
e.g. 1000 ml
8 hours
= 125 ml/hour
2.
3.
152
Examples to try
Calculate the infusion rates for the following:
1.
2.
420 ml blood. How many ml per hour and drops per minute?
Procedure
Figure 7.6
Setting flow
rate.
154
neonatal devices which provide low flow rates in very accurate doses
high-risk infusions such as for intravenous drugs, which require
pumps to deliver at a set, consistent flow rate with a high degree
of accuracy
low-risk infusions for routine fluid administration, e.g. through
gravity-controlled administration sets where regular delivery is
important, but a high level of accuracy is not essential
Only qualified staff should adjust the rate of flow of an infusion pump
as they are held accountable for fluid or drug administration.
155
ALERT!
Alarms may be muted while dealing with problems, but
should never be disabled while the infusion is running, as
serious faults may go undetected. If there is a reason to
believe the alarm is false, check the entire system
including the cannula site. User error may be at fault
rather than the machine (Pickstone 1999), so ensure the
correct equipment is used, and that the patients vein is
patent. If a thorough check does not reveal the problem,
change the pump and seek advice from senior staff.
Volumetric pumps
These are used for highly accurate administration of fluids or drugs and
156
Use the correct infusion set for the type of machine; otherwise,
the infusion can free-flow (Morling 1998).
Ensure the infusion set is inserted in the machine as outlined in
the manufacturers instructions. No force should be required to
insert or remove it.
Move the tubing in the controller every few hours to prevent
compression or tubing damage.
Syringe drivers usually run on batteries, so check the battery indicator regularly to monitor it.
The cannula site may be intravenous or subcutaneous and should
be monitored for any adverse reactions.
Is it delivering at the correct speed? When receiving a handover
157
from the previous shift check the position of the syringe then, and
check it an hour later to ensure it is running as programmed.
Continue to observe its progress regularly throughout the shift to
ensure that faults can be detected speedily and the patients drug
regime is maintained.
Evaluation
Mr Elliots infusion runs according to prescribed schedule.
158
Collect prescribed fluid and check with another nurse against the
prescription sheet: Right patient, Right fluid (drug), Right time,
Right route, and Right dose.
Wash hands.
Open the outer wrapper of the prescribed fluid and check the container for cracks, leaks or breakage in sterility; production date
and expiry date; and clear fluid any discolouration, particles or
cloudiness will indicate contamination.
Invert the bag several times gently, but do not shake to ensure
the solution is well mixed. This is particularly important if potassium or other drugs have been added to prevent layers forming
(Metheny 1990).
Take it to the patient and identify him by name, confirming identity with hospital number on wrist band and prescription sheet.
Place new bag on level surface.
Turn infusion off by closing the clamp. If an electronic pump is
being used stop it.
Take down the old bag from the IV stand and remove it from the
administration set, holding the spike carefully so that it does not
touch anything.
Open the new bag by removing the cap from the port.
IV administration set.
Gloves.
Alcohol rub.
Sterile gauze.
IV dressing or tape.
Protective waterproof pad.
Procedure
Wash hands.
Gather equipment on a clean tray.
Go to the patient and confirm his identity. Explain the procedure
to gain his consent and cooperation.
Turn off current infusion.
Remove the tape that is securing the administration set to the
limb and place a waterproof sheet under the patients arm to protect the bed linen and provide a clean working area. Place the
gauze next to the cannula/administration set connection to soak
up any fluid leaks.
Open the new administration set and close the clamp on it.
Disconnect the old set from the bag, and position it above the
patients heart level.
long enough, the old set can be looped over the IV pole to
TIP! Ifprevent
it from being contaminated or being at a low level.
Connect the new set into the bag, squeeze the chamber to half
full and run through with fluid, excluding air bubbles (see
Commencing intravenous therapy, page 144), and hang up the
bag. Clip the end of the administration set into the roller clamp.
159
Figure 7.7
Applying pressure
to vein above
cannula.
WARNING!
The connection may be difficult to twist open. You may
see small artery forceps being used to hold the cannula
hub to enable disconnection, but this may damage the
cannula hub, so use this method with caution.
160
Remove the protective cap from the new tubing and connect
tubing to the cannula.
Release pressure from finger on cannula.
Recommence fluid flow to check for patency, supporting the cannula so that it does not slip out. If in any doubt, get a qualified
nurse to flush the cannula with 0.9% saline flush.
Retape/redress the cannula hub and IV administration set to
secure it (Figures 7.4 and 7.5 on pages 148 and 149), wiping
around the cannula site with the sterile gauze to remove any leakage during reconnection.
Wash hands. To prevent complications of IV therapy any manipulation of the cannula site or infusion equipment should be undertaken using aseptic principles.
Check infusion site: (a) before and after commencing a new infusion
fluid; (b) when assisting Mr Elliot to wash or dress; (c) before and
during IV drug administration; (d) when checking flow rate.
Observe for: (a) swelling and colour of limb or around cannula
entry site: this may indicate infiltration or extravasation; (b) evidence and extent of inflammation, redness or pain: this may suggest phlebitis, infection or nerve injury; (c) leakage from cannula
site, slowing or stopping of infusion flow: this may indicate a
blocked cannula, possibly from venospasm or infiltration, and may
occur especially at night (Campbell 1997); (d) secure dressing or
taping of the cannula: if loose, this allows the cannula to move
and irritate the vein and may lead to phlebitis; (e) correct rate of
fluid delivery: too much may lead to fluid overload, or if it contains a drug may lead to speedshock.
If any of these are present, stop the infusion and report to senior
staff. If the cannula is loose, provided there are no local signs
of inflammation or infection it may be secured and redressed
following aseptic principles. (See Commencing intravenous
therapy, page 150.)
161
Summary of IV complications
Local complications
Infiltration
Also known as tissuing. Fluid no longer enters the vein, because either
the cannula has slipped out of the vein or the vein has collapsed,
causing a blockage and backflow of fluid into the interstitial spaces
(Hecker 1988).
Signs/symptoms: Swelling, cool blanched skin, leakage from can-
Extravasation
This is when vesicant (toxic) drugs, e.g. 10% or 20% dextrose, or cytotoxic drugs have infiltrated the tissues rather than isotonic fluid, and
cause tissue damage (Lamb 1996).
Signs/symptoms: As above, but swelling may be rapid and re-
162
dote or hydrocortisone injection. Extravasation can result in tissue necrosis if not corrected quickly.
Phlebitis
The inner lining of the vein is irritated by:
Thrombophlebitis
This is when a thrombus (blood clot) forms inside the inflamed vein.
Signs/symptoms: Severe discomfort, inflammation visibly track-
Nerve injury
This may result from the swelling caused by infiltration or extravasation, poor location of cannula, too many attempts at cannulation, or
bandaging or splinting too tightly or in an abnormal position (Masoorli
1995; Dougherty 1996).
163
Systemic complications
Bacteraemia
Micro-organisms in the blood. May go undetected until septicaemia
develops.
Septicaemia
Presence of pathogenic bacterial toxins in the blood.
Signs/symptoms: General malaise, pyrexia, rigors, nausea, vomit-
ing and hypotension (Lamb 1996). May have evidence of inflammation at cannula site and along the vein, but may be no visible
inflammation.
Interventions: Notify the doctor. Take vital signs. Prevention
requires maintenance of scrupulous aseptic technique whenever
manipulating the IV equipment. Always wash hands before and
after touching the system. Keep the number of extensions and
three-way taps to the minimum. Change whole system every
4872 hours. Monitor cannula site for signs of infection. Blood
cultures taken and the cannula tip should be sent for microscopy,
sensitivity and culture. IV antibiotics and additional therapeutic
interventions will be required.
Emboli
Air, particle, catheter or thrombus; occurs when a foreign body enters
the circulation and travels until it occludes a small vessel:
164
Circulatory overload
This can occur when too much fluid has been infused and the patient
is not able to disperse it naturally. It may happen due to a fault in an
IV pump or administration set, or positional cannula, or due to overtransfusion.
Signs/symptoms: Discomfort, neck vein enlargement, respiratory
Drug incompatibility
Patients who are receiving IV drugs may be prescribed drugs that are
incompatible with each other, which if administered through the same
or connecting IV administration sets may result in a chemical reaction
causing particles to form in the infusion.
Signs/symptoms: Blocked cannula, poor infusion flow, evidence
Speedshock
Caused by the rapid infusion of an IV drug resulting in a toxic blood
concentration.
Signs/symptoms: Flushed face, headache, dizziness, chest tight-
Anaphylactic/allergic reaction
This is a result of allergen or drug reaction and can be very sudden and
life-threatening.
Signs/symptoms: Itching, rash, watering eyes, sneezing, broncho-
Removal of cannulas
Cannulas should be removed as soon as possible after therapy has been
discontinued (Spencer 1996), otherwise patients could be exposed to
unnecessary infection risks.
166
Sterile gauze.
Hypoallergenic tape.
Gloves.
Small sharps disposal box.
Procedure
Wash hands.
Collect equipment on a clean tray.
Explain the procedure to Mr Elliot and gain his cooperation.
Provide privacy.
If infusion is still in progress, turn off. Record amount of fluid
administered.
Put on gloves.
Open gauze swabs.
Loosen dressing and remove from the skin. An elderly patients
skin may be fragile and tear easily (Whitson 1996), so ease off
gently. Observe site for signs of inflammation or infection.
With your non-dominant hand, put pressure over the end of the
cannula in the vein.
Fold a piece of gauze in half and hold in your non-dominant hand.
With your dominant hand, withdraw cannula. As soon as it has
been removed place the folded gauze on the entry site and apply
pressure for 23 minutes until bleeding stops.
Apply a fresh piece of gauze and secure with hypoallergenic tape.
If infection or localized tissue damage is present, apply appropriate
dressing.
Dispose of equipment, placing cannula in sharps container.
Ensure Mr Elliot is comfortable and has all he needs.
Record removal in the nursing notes, documenting your observations of the condition of the site. Observe the site closely over the
next 24 hours to ensure that post-infusion phlebitis does not occur
(Millam 1988). If there are no signs of inflammation or infection the dressing can be removed after 812 hours, and the site
exposed.
Evaluation
Mr Elliots infusion site heals with no complications or discomfort.
Blood transfusion
The aim of a blood transfusion is to increase the oxygen delivery to the
tissues in a short time (Togshill 1997). It is the most effective method
of replacing acute blood loss, but whole blood is rarely used as various
167
blood loss.
Red cells
Contents: Concentrated red cells, reduced plasma component, in
Platelets
Contents: Concentrated platelets in plasma, with red cells removed.
Uses: To treat clotting abnormalities as a result of large transfusions
of collection.
Uses: Bleeding disorders where clotting factors are absent.
168
Patient history
Mr Ammon has been involved in a road traffic accident (RTA) having
been knocked off his motor cycle. He has a suspected fractured pelvis,
left fractured femur and a right compound fracture of tibia and fibula,
and possible internal injuries. It is estimated that he will need at least
four units of blood to compensate for the blood loss from the accident
and the surgical operation.
adverse reactions.
Goal: Prevention and early detection of adverse reactions to blood
transfusion.
The request form must include surname, first name, gender, date
of birth, hospital number.
Blood samples should be labelled directly after collection and
while beside the patient so that details can be checked immediately. Addressograph labels should not be used on sample tubes.
Any factors, such as previous transfusions and current medication
that may contribute to potential complications should be identified during preliminary nursing and medical assessments for transfusion (Bradbury and Cruickshank 2000).
Prescription sheet.
Compatibility form.
Fluid balance chart.
Disinfected tray containing the following:
IV cannula; usual size for blood transfusion is 21 gauge
(green) or above (19 or 20 gauge).
Alcohol wipes or chlorhexidine cleanser.
Blood administration set.
IV pole/stand.
Sterile dressing and tape or semi-permeable transparent IV
dressing.
Gloves.
IV access
This is the final opportunity to detect any errors of incompatibility. Unfortunately failure to follow stringent procedures has resulted in
fatalities (Gray and Murphy 1999). The qualified nurse is as accountable for safety during transfusion as during drug administration. As an
unqualified practitioner, you may find yourself checking blood with a
qualified practitioner, and should remain accountable for your actions.
Be vigilant at all stages, even if Trust policy considers the qualified
practitioner as ultimately responsible as if administering a drug singlehandedly. Blood unit numbers can be long and mistakes can easily be
made.
Final checks
All checks should be done at the patient bedside (Gray and Murphy
1999):
Figure 7.8
Blood unit
details.
172
173
ALERT!
The blood group ABO and Rhesus factor on the blood unit
and compatibility form should be identical. In cases of
emergency transfusion, O Rhesus negative may be used
as it is the universal donor (Table 7.1). If there is any doubt
or discrepancy between the group on the blood unit and
the blood group of the patient, contact the blood bank
immediately and do not commence the infusion.
No drugs should be added to the blood or administration
set as they could contaminate or react with the blood. If
intravenous drugs are required ensure that the patient has
two patent IV access sites, or a Y type cannula may be
used, depending on local policy.
Approximately 85 per cent of people in the UK are Rhesus
D positive. Those who are Rh D negative have no Rhesus
antigen, but a Rh D antibody can be produced after
exposure to Rh D positive blood (Glover and Powell 1996).
This will have consequences for the recipient so check
that the Rh D is compatible.
Compatible groups
Percentage in UK
O
A
B
AB
O
A and O
B and O
AB, A, B, and O
47 (O Rh ve = universal donor)
42
8
3 (AB Rh +ve = universal recipient)
173
ALERT!
Only 0.9% saline solutions should come into contact with
blood or blood products. If dextrose is given it will cause
haemolysis (breakdown of red blood cells).
174
Mr Ammon should be advised to report any feelings of breathlessness, loin pain, abdominal discomfort, shivering, or feeling
unwell. He should be observed for pyrexia, tachycardia, rashes,
flushing or blood in his urine. If any of these occur stop the transfusion and seek medical advice.
Documentation of vital signs and blood pack details should be
completed and maintained throughout the treatment. Should any
adverse reactions occur (see section below) inform senior nurse
and medical staff. Document your response and interventions in
the nursing record.
A permanent record of the following should be kept in the medical notes (Gray and Murphy 1999):
type of transfusion of blood or blood products
compatibility form
nursing observation record
indications for and response to the transfusion
occurrence and management of adverse reactions.
A fluid balance record should be maintained, recording the
amount of each unit, the patients overall fluid balance and if
blood was detected in the urine during transfusion.
On completion the blood bag is sealed with the attached bung,
placed in an outer bag, and discarded or returned to the haematology department, depending on the local policy. A new administration set should be used for any subsequent fluids, or the cannula may
be removed.
175
Evaluation
Mr Ammon receives a blood transfusion without adverse reactions.
Allergic reaction
Mild: Urticarial rash (hives), pyrexia.
Severe: Facial oedema, bronchospasm.
Actions: Stop infusion; administer antihistamines. In case of a severe
Infections
Symptoms: Pyrexia, rigors, hypotension, phlebitis at IV site.
Actions: Stop infusion. Inform medical staff. Save unit of blood and
Haemolytic reaction
Symptoms: Destruction of donor red cells by recipient causing:
176
Circulatory overload
Symptoms: Breathlessness; cough; distress.
Actions: Stop or slow infusion; diuretic therapy; monitor urine
output.
drugs such as IM epinephrine and IV piriton should
TIP! Emergency
be readily available when blood transfusions are in progress in
case of allergic reaction.
Further reading
Amoore J, Dewar D, Ingram P, Lowe D (2001) Syringe pumps and start up time: ensuring safe practice. Nursing Standard 15(17): 4345.
Bradbury M, Cruickshank JL (2000) Blood transfusion: crucial steps in maintaining safe
practice. British Journal of Nursing 9(3): 13438.
Morling S (1998) Infusion devices: risks and user responsibilities. British Journal of
Nursing 7(1): 1319.
Woollon S (1997) Selection of intravenous and infusion pumps. Professional Nurse
Supplement 12(8): S14S15.
Workman B (1999) Peripheral intravenous therapy management. Nursing Standard
14(4): 5360.
177
CHAPTER 8
Respiratory care
Clare Bennett
Respiratory assessment
The respiratory tract is made up of the nose, pharynx, larynx, trachea,
bronchi and lungs. A problem arising in any part of the tract may result
in breathlessness. Additionally, disturbances in the circulatory, haematological and metabolic systems have the potential to affect normal
respiratory patterns.
Respiratory assessment begins with observing a patients general
appearance. Factors to observe include:
178
Respiratory care
The third aspect of respiratory assessment uses physical examination and observations. These will be explained in the following
nursing interventions. The specific values and times have not been
179
Normal values
Normal respiratory values will vary according to a patients age, gender
and medical history. The normal rate of breathing at rest is 1220
times per minute for a healthy adult.
Terminology
apnoea
bradypnoea
dyspnoea
hyperpnoea
tachypnoea
Normal breathing
On inspiration the diaphragm descends, the lower part of the rib cage
moves upward and outward and there is slight expansion of the upper
chest. Expiration is passive and is slightly longer than inspiration. A
short pause is normal between expiration and the next inspiration.
Chest movement should be equal, bilateral and symmetrical. It is
important to monitor the respiratory rate, rhythm and depth of any
patient who has an altered respiratory status.
Normal breathing should be barely audible to the naked ear, but
with a stethoscope will be equal on both sides and audible in all the
lung zones. The following sounds are significant:
180
Respiratory care
per minute).
Goal: Mr Browns respirations will return to normal parameters
182
Respiratory care
Equipment
Pulse oximeter.
Appropriate sensor.
Trolley/table to mount monitor on.
Procedure
ALERT!
Never attach a finger sensor by using adhesive tape, since
this has the potential to cause tissue necrosis.
184
Respiratory care
Equipment
Figure 8.1
The MiniWright peak
flow meter.
Procedure
TIP! Additional
monitoring effectively.
186
frequency
length of time coughing takes
Respiratory care
These observations should be noted in Mr Browns notes and communicated to other members of the care team.
ALERT!
When administering oxygen it is essential that the following
precautions are observed to prevent fire:
Smoking in the area is prohibited.
Signs regarding the prohibition of smoking are displayed.
Matches and lighters should be removed from the
patients bedside.
The use of oil- and alcohol-based skincare products is
avoided.
187
ALERT!
Oxygen should always be prescribed by a doctor, stating
the flow rate, delivery system, duration and monitoring
of treatment.
188
Specific levels of air entry so that air is mixed with the oxygen
administered, to deliver precisely controlled percentages of high
flow oxygen at low to mid concentration (2460 per cent).
The valves are colour coded according to the percentage of
Respiratory care
Figure 8.2
Venturi mask.
Humidification devices
Humidification devices vary between Trusts and include:
aerosol generators
humidified ventimask systems
condensers
water bath humidifiers.
189
Figure 8.3.1
Hudson mask.
Figure 8.3.2
Nasal cannula.
Respiratory care
Procedure
192
Respiratory care
ALERT!
The administration of oxygen, except in a very low concentration (2428 per cent), could be fatal to patients with
chronic pulmonary disease. This is because carbon dioxide
is retained in the blood (chronic hypercapnia) and the
chemoreceptors in the brain become less sensitive to high
blood levels of carbon dioxide. The patient then becomes
dependent on low oxygen (hypoxia) to stimulate respiration. Thus if oxygen is given to correct hypoxia, the
patients respiratory drive may be removed.
193
Equipment
Procedure
194
Prepare equipment.
Encourage Mr Brown to sit upright and take some deep breaths.
Ask Mr Brown to cough and expectorate into the specimen container. Several coughs may be required to obtain a sufficient specimen. Some patients may need to be taught by a physiotherapist
how to cough effectively and expectorate without strain.
Seal the lid and complete Mr Browns details on the specimen pot.
Place pot and laboratory request form in a plastic specimen bag
and send to the appropriate laboratory. Wash hands. If a delay in
transporting the specimen to the laboratory is envisaged place it
in the refrigerator immediately.
Offer the patient a mouthwash and tissues.
Document that a specimen has been obtained, noting colour,
smell and consistency.
Respiratory care
Evaluation
Has Mr Browns respiration reverted to its normal rate, rhythm and
depth? Has his colour and perfusion improved? If Mr Browns respiration has not returned to its normal pattern within the stated time the
plan of care will need to be revised accordingly.
summer when the pollen count is high. She has just been admitted to the ward with an acute asthma attack.
Problem: Mrs Jones is experiencing difficulty in breathing due to
acute severe asthma.
Goal: Mrs Jones respiratory status will return to her normal measurements.
Interventions
Mrs Jones requires all the care described for Mr Brown. However,
because the cause of her respiratory distress is known it is possible to be
more specific about certain aspects of her care. These are listed below,
and described above in more detail, in Mr Browns care plan. The
interval between observations has not been given since the degree of
her respiratory distress is not known.
Observe and record Mrs Jones respiratory rate, depth and rhythm
every x hours.
Observe for evidence of cyanosis.
Record Mrs Jones pulse oximetry every x hours.
195
Bronchodilators, steroids, antibiotics, rhDNase, pentamadine, lignocaine and 0.9% sodium chloride are available for nebulization. Water
should not be nebulized since it may cause bronchoconstriction (Muers
and Corris 1997).
196
Respiratory care
Nebulizers with masks are better for acutely ill patients who may
find holding the nebulizer tiring.
Nebulizers with mouthpieces should be used:
ALERT!
Patients with acute severe asthma should have their nebulizers administered via oxygen or they will become hypoxic.
Air should be used for all other lung diseases unless oxygen
is prescribed. If necessary, low-flow oxygen can be administered via nasal cannulae to patients while a drug is nebulized with air. This is because it requires a high flow of oxygen to nebulize a drug (68 litres/minute) and if the patient
has chronic respiratory disease he will require only a low
level of oxygen to stimulate his respiration.
197
Procedure
Respiratory care
Evaluation
Has Mrs Jones experienced relief in response to the interventions?
Have her vital signs changed towards her normal parameters?
Short-acting bronchodilators
These are also known as relievers. Examples include Salbutamol and
Ipratropium Bromide. These drugs have varying speeds of onset of
effect. For example, Salbutamol may have an effect within 5 minutes
yet Ipratropium Bromide may take 20 minutes before an effect is felt.
Inhalers in this group are usually coloured blue or grey.
Long-acting bronchodilators
Salmeterol is an example of this group. These drugs have long-lasting
actions (e.g. a 12-hour effect) but take longer to act initially. These
drugs are therefore prescribed for regular administration, such as twice
daily, rather than on an as required basis. These inhalers are usually
green in colour.
199
Inhaled steroids
These are also known as preventers. These drugs have an anti-inflammatory effect. They have a slow onset of action and patients may feel no effect
for several days after commencing treatment. Inhaled steroids should be
taken regularly every day, even when the patient feels well, to prevent an
increase in inflammatory changes in the bronchioles. These inhalers are
brown/red/orange/pink in colour. The mouth should be rinsed out after
inhaling steroids, to prevent the development of oral thrush.
To ensure that the maximum amount of drug is deposited in the lungs,
it is imperative that an appropriate device is chosen and that the
patients technique is adequate. Many metered dose inhalers (MDIs)
require considerable strength on the index finger and thumb to activate the aerosol release: finger strength, manual dexterity and coordination therefore need to be assessed. In addition, the patients memory needs to be assessed, so that if required a simpler inhaler can be prescribed or a carer can help to give it.
Inhaler technique
Before teaching a patient it is advisable to assess his or her knowledge
of the subject. This can prevent unnecessary repetition and can also
identify areas of misunderstanding. In this instance you could ask Mrs
Jones to tell you what she knows about her inhaler and to demonstrate
how she thinks it should be used.
Everybody learns in a different way, and it is important to assess
how Mrs Jones learns best. Mrs Jones may find that it is useful to learn
inhaler technique by having the procedure broken into easy stages and
repeating these until the final stage is learnt and the whole procedure
accomplished. However, some patients feel more comfortable with
written guidance, private practice and finally performance in front of
a health care professional. Other patients may have problems with
understanding English and others may be unable to read. Ask Mrs
Jones how she learns a practical skill before you start.
Using the above information, a teaching session will need to be
devised to facilitate Mrs Jones in learning to use her inhaler. In certain
200
Respiratory care
Figure 8.4
Metered dose
inhaler.
Breath-actuated MDIs
These inhalers (e.g. Autohalers and Easi-breathe) are activated by the
patients inspiration. These devices can help overcome coordination
problems (Figure 8.5).
Figure 8.5.1
Autohaler.
Figure 8.5.2
Easi-breathe
device
202
Respiratory care
NB: the lever must be pushed up (On) before each dose, and pushed down
again (Off) afterwards, otherwise it will not operate.
203
Figure 8.6.1
Spinhaler.
Figure 8.6.2
Rotahaler
Figure 8.6.3
Aerohaler.
Figure 8.6.4
Accuhaler.
Figure 8.6.5
Diskhaler
Figure 8.6.6
Turbohaler
204
Respiratory care
Spacer devices
If a patient uses a spacer device in hospital it should be named so that
others do not use it so reducing the risk of cross-infection. Spacer
devices offer the following advantages:
Ensure that the spacer and inhaler are compatible. Each make
varies and they are not interchangeable.
Place the two halves of the spacer together.
Remove the cap and shake the inhaler. Place mouthpiece of
inhaler into port of spacer (Figure 8.7).
Figure 8.7
Volumatic
spacer device.
Sit upright.
Breathe out gently. Place lips around spacer mouthpiece.
205
Hold spacer level and place one actuation into the spacer.
Inhale slowly and deeply. If a deep inhalation is not possible the
patient should breathe in deeply several times, exhaling into the
canister.
Remove the inhaler from mouth and keep mouth closed.
Hold the breath for 10 seconds or as long as possible.
Repeat the procedure as required, waiting approximately 30 seconds
between each actuation.
FIRST
AID
TIP!
Evaluation
In order to evaluate whether the goal has been met the following questions could be used when checking Mrs Joness inhaler technique:
206
Respiratory care
unconscious or semi-conscious patients, e.g. post-operative recovery patients who are vomiting and do not have a gag reflex to prevent them from inhaling vomit or secretions
patients who have had oral surgery or trauma resulting in blood
and mucous secretions which need to be removed
patients who are too weak to expectorate sputum from the pharynx.
Oral and nasopharyngeal suction are not the same as tracheal suction
as they do not completely occlude a patients airway. As suctioning by
these routes does not enter a sterile area the procedure is clean, rather
than aseptic. However, the Yankuer (oral) sucker should be used for
one patient only and changed daily. It can be a very distressing procedure for the patient and should not be undertaken for prolonged
periods. It may be used in conjunction with a Guedel airway if the airway needs to be maintained.
207
Explain procedure to Mr Barrett. (Even if the patient is unconscious explanations should be given, since many unconscious individuals are able to hear.)
Wash hands.
Prepare equipment.
Attach suction tubing to suction machine and attach oral sucker
to suction tubing, ensuring a tight fit.
208
Respiratory care
your breath while you suction because when you feel the
TIP! Hold
need to breathe again that will indicate that the episode of
suctioning is long enough.
209
patients with a lot of secretions at the back of the throat but who cannot cough or expectorate. It may be used in conjunction with a
nasopharyngeal airway, which is tolerated quite well by semi-conscious
patients.
Equipment
Procedure
210
Explain procedure to Mr Barrett. (Even if Mr Barrett is unconscious, explanations should be given, since many unconscious
individuals are able to hear.)
Wash hands.
Prepare equipment.
Attach suction tubing to suction machine and attach oral sucker
to suction tubing, ensuring a tight fit. Check that the suction
machine and equipment are working.
Position Mr Barrett in a semi-recumbent position with head
turned towards you. If he is unconscious he should be nursed semiprone, facing you.
Place a towel or pad under Mr Barretts chin.
Switch the suction machine on and set suction level for up to 20
kPa or 120 mmHg for wall suction units (see Oral suction). It is
important that excessive suction is not used since this may cause
damage to the mucosa.
Put on gloves, eye shield and mask.
Attach a sterile catheter to the suction tubing and approximate
the distance between the patients ear lobe and tip of the nose,
marking this point with gloved thumb and forefinger. This ensures
that the catheter length inserted will remain in pharyngeal area
and not enter the trachea.
Moisten the catheter tip with sterile water and apply suction to
Respiratory care
sterile water. This will lubricate the tip to ease insertion and
ensures that the equipment is working.
Without applying suction (see above) insert the catheter into one
nostril. Guide it along the floor of the nasal cavity. If there is any
obstruction, remove catheter. Apply suction and gently rotate the
catheter as you withdraw it to gather secretions on removal.
The procedure should take no longer than 15 seconds to prevent
damage to the patient due to oxygen insufficiency. Observe Mr
Barretts colour and facial expression to detect signs of respiratory
distress. If the procedure stimulates coughing the catheter has
entered too far into the respiratory passages and should be withdrawn.
Use the catheter once and then discard by wrapping it around your
gloved hand and taking off the glove with the catheter inside.
Clean the suction tubing by suctioning through sterile water until
all debris has been cleared.
Allow Mr Barrett to rest for at least 30 seconds before repeating
the procedure. There should be an audible improvement in his
breathing if suction is effective.
Wash hands.
Document the quantity, colour, consistency and odour of secretions and the patients response to the procedure.
ALERT!
The older adult with cardiac or pulmonary disease may be
able to tolerate only 10-second periods of suctioning since
they are at greater risk of developing cardiac arrhythmia
as a result of hypoxia (Perry and Potter 1998).
211
Evaluation
Evaluation of the care given to Mr Barrett will focus upon whether his
airway remains free of secretions. If Mr Barretts level of consciousness
alters, the plan of care will need to be reviewed accordingly.
Further reading
Abley C (1997) Teaching elderly patients how to use inhalers: a study to evaluate an
education programme on inhaler technique for elderly patients. Journal of
Advanced Nursing 25(4): 699708.
Bell C (1995) Is this what the doctor ordered? Accuracy of oxygen therapy prescribed
and delivered in hospital. Professional Nurse 10(5): 297300.
Cowan T (1996) Nebulisers for use in the community. Professional Nurse 12(3):
21520.
Dodd M (1996) Nebuliser therapy: what nurses and patients need to know. Nursing
Standard 10(31): 3942.
Fell H, Boehm M (1998) Easing the discomfort of oxygen therapy. Nursing Times
94(38): 5658.
Finkelstein L (1996) Sputum testing for TB: getting good specimens. American Journal
of Nursing 96(2): 14.
Grap MJ (1998) Protocols for practice: applying research at the bedside pulse oximetry. Critical Care Nurse 18(1): 9499.
Hall J (1996) Evaluating asthma patient inhaler technique. Professional Nurse 11(11):
72529.
Jain P, Kavuru MS, Emerman CL, Ahmad M (1998) Utility of peak expiratory flow
monitoring. Chest: The Cardiopulmonary Journal 114(3): 86176.
Manolio TA, Weinmann GG, Buist AS, Furberg CD, Pinsky JL, Hurd SH (1997)
Pulmonary function testing in population-based studies. American Journal of
Respiratory and Critical Care Medicine 156(3, Pt. 1): 100410.
Mathews PJ (1997) Using a peak flow meter: monitoring the air waves. Nursing 27(6):
5759.
McConnell EA (1999) Clinical dos and donts: performing pulse oximetry. Nursing
29(11): 17.
Muers M, Corris P (1997) Current best practice for nebuliser treatment. Thorax: the
Journal of the British Thoracic Society 52(Supp. 2).
OCallaghan C, Barry P (1997) Spacer devices in the treatment of asthma. British
Medical Journal 314(7087): 106162.
212
Respiratory care
213
CHAPTER 9
Assisting patients
to meet their
nutritional needs
Clare Bennett
Aims and learning outcomes
This chapter discusses the effect of malnutrition upon an individuals
health and how it can be prevented or corrected. By the end of the
chapter you should be able to:
define malnutrition
discuss the incidence and impact of malnutrition in the community and hospital settings
feed a patient via the oral route safely
describe indications and contraindications for nasogastric tube
feeding, the procedure required for tube insertion, and patient
care after nasogastric tube insertion
describe indications and contraindications for percutaneous endoscopic gastrostomy (PEG) feeding, and patient care pre- and postinsertion.
Patient assessment
Malnutrition occurs when there is an imbalance between what a person eats and what is needed physiologically. Evidence suggests that up
to 10 per cent of chronically sick individuals in the community are
malnourished (Edington et al. 1996), and in hospital up to 60 per cent
of patients in certain wards do not consume adequate protein or calories (Bond 1997). Poor nourishment can result in various problems
(Clay 2001; Ward and Rollins 1999):
214
muscle atrophy
increased risk of pressure sore development
delayed healing
depressed immunity
decreased muscle strength
increased liability to heart failure
depression and apathy
social isolation.
hemiparesis
poor manual dexterity
visual impairment
swallowing problems
lethargy
environmental problems
poor or lost appetite.
Although a loss of appetite will not physically prevent the patient from
feeding himself it may present a significant psychological barrier. A
thorough nutritional assessment may identify a specific cause and help
to plan appropriate interventions.
Patients generally prefer to maintain their independence and feed
themselves where possible, and this should be encouraged. Support for
215
216
sary. Some patients avoid going to the dentist and then cannot eat
because of tooth decay and oral discomfort.
Mr Holmes should be given a choice as to whether he wishes
to eat in privacy or with others. Meals are a social occasion and
people may eat more in company. The exception to this is if other
peoples eating habits are a distraction for Mr Holmes.
The eating environment should be free of reminders of treatments
and unpleasant odours.
Mouth care prior to food and drink may be required to remove any
unpleasant tastes from the mouth associated with treatments or
infection.
Mr Holmes should be offered the opportunity to visit the toilet
and wash his hands prior to meal times.
Lethargy
Hemiparesis
A plate guard and non-slip mat may help if Mr Holmes is only able
to use one hand to eat. Using a feeding beaker may help if he has
a one-sided weakness to the mouth.
Nutritional supplements and food fortification may be required if
Mr Holmes finds feeding particularly tiring.
The nurse should give assistance with opening awkward packaging such as yoghurt tops and sandwich containers.
It may be useful to cut up Mr Holmess food for him. This should
be done sensitively so that Mr Holmes does not feel he has
regressed to childhood.
Visual impairment
A non-slip mat and plate guard may be useful depending upon the
severity of Mr Holmess impairment.
Orientate Mr Holmes to where things are on the plate. Clock face
positions may be useful, e.g. The salad is at five oclock, the
chicken is at twelve oclock, etc.
Poor appetite
218
(1997) stresses that the presentation of food is extremely important; she suggests the use of thickening agents to make pured
food look like it did before it was put into the food processor.
Thickening agents added to drinks may help swallowing depending upon the speech and language therapists assessment.
Observe Mr Holmes for choking when commencing a pureeed or
soft diet.
Evaluation
Mr Holmes may respond to some of these measures to improve his food
intake. Take note of the interventions that help him and persist with
them until his needs change.
Establish whether there are any dietary restrictions, or contraindications to oral feeding.
Consider environmental issues.
Wash and dry hands and put on an appropriately coloured apron.
Obtain the items that Mr Holmes would like to drink and/or eat,
appropriate cutlery and a napkin.
Present the meal as attractively as possible, place the meal on a
table in front of Mr Holmes and place a seat to one side for yourself.
Protect Mr Holmess clothes with the napkin.
Sit down and start to feed Mr Holmes. Allow him to direct the
order in which he wishes to eat the food. Allow time for him to
empty his mouth completely between each spoonful, aiming to
match the speed of feeding to his readiness. Ask Mr Holmes
whether the speed at which you are feeding him is acceptable. Try
to engage in conversation about everyday topics to create a more
relaxed atmosphere, but avoid asking questions when Mr Holmes
is eating.
Remove any spillages on the chin, face and neck with a napkin.
If Mr Holmes likes to drink during his meal ensure you offer him
fluids at appropriate intervals.
219
Evaluation
Has Mr Holmes increased his food intake? Is his appetite improving? Is
he increasingly independent at meal times? Is Mr Holmes receiving an
adequate balanced diet for his needs? If eating aids are being used, were
they suitable and did he use them?
Monitoring these factors will indicate whether the care plan is
effective.
220
metabolic abnormalities
hypercatabolic states: e.g. sepsis; burns; major trauma, including
surgery
psychological problems causing loss of appetite.
intestinal obstruction
paralytic ileus
diffuse peritonitis
intractable vomiting
severe diarrhoea
severe malabsorption
short bowel syndrome
certain cases of severe pancreatitis, high output gastro-intestinal
fistulae and gastro-intestinal ischaemia, although enteral nutrition
may sometimes still be feasible
basal skull fractures
when prolonged feeding is required (longer than 24 weeks).
administered via a 6 Fr tube; more viscous feeds such as those containing fibre should be delivered via an 8 Fr tube to prevent tube
occlusion (Rollins 1997).
stroke affecting his left cerebral hemisphere that has affected his
speech and swallowing mechanisms and resulted in a right hemiparesis (paralysis of the right side).
Problem: Mr Palmer cannot eat enough orally to meet his nutritional needs due to an impaired swallowing reflex following a
stroke.
Goal: Mr Palmer will receive a balanced nutritional intake, totalling
a calorific intake of x calories in 24 hours via a nasogastric tube.
222
Procedure
Figure 9.1
Measuring the
length of an
NG tube.
223
ALERT!
If the patient shows signs of distress, e.g. coughing,
gasping or breathlessness, remove the tube immediately
as it may have entered the bronchus.
224
ALERT!
Auscultation (listening) alone is not sufficient to confirm
the correct position of the tube since it is very easy to
misinterpret where the air sounds are coming from. Both
litmus testing and auscultation are necessary.
Recommended practice requires that an abdominal X-ray
should confirm correct positioning. If there is any doubt
about the position of the tube, or if it has been difficult to
pass, a chest X-ray should be carried out to ensure that it
is not in the lungs, before any feed is commenced (Loan
et al. 1998).
ALERT!
Never reinsert a guide wire once it has been removed.
Firmly secure the tube using soft tape in a position that is acceptable to Mr Palmer, for example, under his cheekbone, and loop it
over the ear.
Help Mr Palmer to assume a more comfortable position, and provide all he needs within easy reach.
Dispose of equipment, remove gloves, wash hands.
Record all actions in Mr Palmers documentation.
225
Flush the tube with water before and after feeding; and before, after
and between the administration of medication; 6-hourly flushes are
recommended if feeding continuously (Colagiovanni 2000).
Research has not yet confirmed the quantity of water that should
be used for flushing, although Burnham (2000) recommends a
minimum of 20 ml.
If the tube is not being used, it should be flushed regularly with
water, although research has not identified the frequency for
flushing. Common sense would suggest 6-hourly flushing although
there is little supporting evidence for this.
Polyurethane tubes are preferable to silicone tubes as they appear
to block less readily (Colagiovanni 2000).
When administering medication, dispersible preparations should
be used where possible and syrups should be diluted with water. If
tablets have to be crushed they should be mixed thoroughly with
water prior to administration. If more than one drug is required,
the tube should be flushed with water between each drug (Colagiovanni 2000; see Chapter 6).
If 46-hourly aspiration is required to assess gastric absorption,
tubes are more likely to become blocked. It is therefore advisable
to use a wide-bore tube until gastric emptying is confirmed, and
then replace it with a fine-bore tube (Colagiovanni 2000).
If the tube blocks, water or carbonated drinks may be useful in dispersing food clots (Colagiovanni 2000). Force should not be used
to introduce these substances as this may cause the tube to split
(Baeyens et al. 1999).
ALERT!
When flushing the tube, the manufacturers guidelines
regarding syringe size must be adhered to, to prevent
splitting of the tube. Generally syringes need to be greater
than 30 ml (Rollins 1997).
226
Feeds are usually given continuously or overnight, although occasionally some patients may have bolus feeds at their usual meal times.
ALERT!
The position of the tube must be checked every 24 hours,
and after physiotherapy, vomiting, regurgitation or violent
coughing.
Prepare equipment.
Explain procedure to Mr Palmer.
Wash hands.
Confirm correct position of tube using litmus test, auscultation
and X-ray as described above.
Wash hands.
Flush tube with a minimum of 20 ml water (Burnham 2000).
Wash hands.
227
Clean facial skin daily with mild soap and water depending on a
patients preference; dry thoroughly and apply fresh tape.
Clean nostrils daily, removing crusts and discharge.
Check for skin erosions on nasal mucosa, the edge of the nostrils,
skin underneath the tube and behind the ears.
Alter the position of the tube to relieve these areas on the face
and ears frequently.
Provide regular oral hygiene, especially if Mr Palmer is not able to
take anything orally.
Evaluation
Has Mr Palmer received a balanced diet by NG tube? Is he able to
absorb the tube feed? Has his skin remained intact?
oesophagus and will be unable to take fluid and diet by the oral
route for some time until his treatment is complete. He is to have
a percutaneous endoscopic gastrostomy (PEG) tube inserted for all
his nutritional needs.
Problem: Mr Hamilton needs to be physically and psychologically
prepared for a percutaneous endoscopic gastrostomy (PEG).
Goal: Mr Hamilton will be physically and psychologically prepared
for the procedure.
230
body image that will affect him. An experienced nurse may help
Mr Hamilton make some significant psychological adjustments
(White 2000). Some Trusts have specialist nutrition nurses available for counselling prior to the procedure.
Ensure that Mr Hamilton will have nil by mouth for 6 hours prior
to the procedure to prevent aspiration. This should be explained
clearly to Mr Hamilton so that he appreciates that the successful
outcome of the procedure requires an empty stomach.
Ensure that written consent is obtained and that details of explanations of the procedure are documented in Mr Hamiltons
records.
Ensure that Mr Hamiltons full blood count and clotting levels are
recorded. It is essential that appropriate doctors are made aware of
the results in case there are abnormalities to be corrected.
Administer any prescribed sedation and prophylactic antibiotics.
This ensures Mr Hamilton is comfortable and relaxed, and potential infection from flora from the gastrointestinal tract is limited.
Evaluation
Did Mr Hamilton undergo the procedure with minimal discomfort?
Were all his questions answered beforehand? Has he adapted fully to
the change to PEG tube?
231
232
Clamp for the minimum time necessary, using the plastic clamp
provided by the manufacturers. A metal clamp should never be
used. The tube should be closed but does not need to be clamped
when it is not in use.
Flush with water before and after feeding, and before, after and
between the administration of medication.
If not in use, flush the tube regularly with water.
When administering medication, use dispersible preparations
where possible and dilute syrups with water. If tablets have to be
crushed they should be mixed thoroughly with water prior to
administration. If more than one drug is required the tube should
be flushed with water between each drug (Colagiovanni 2000).
Evaluation
Evaluation of the care provided will focus upon whether infection was
prevented and the patency of the PEG maintained.
233
Evaluation
Has Mr Hamilton received a balanced diet and the required number of
calories? This will be measured through accurate recording of the daily
nutritional intake. If the goal has not been reached, the plan of care
will need to be revised accordingly.
Further reading
ACHCEW (1997) Hungry in Hospital? London: Association of Community Health
Councils of England and Wales.
Arrowsmith H (1997) Malnutrition in hospital: detection and consequences. British
Journal of Nursing 6(19): 113135.
Baker F, Smith L, Stead L, Soulsby C (1999) Inserting a nasogastric tube. Nursing Times
95(7), Insert 2p.
Bliss DZ, Lehmann S (1999) Tube feeding: administration tips. Registered Nurse 62(8):
2932.
Buckley PM, MacFie J (1997) Enteral nutrition in critically ill patients a review. Care
of the Critically Ill 13(1): 710.
Carriquiry AL (1999) Assessing the prevalence of nutrient inadequacy. Public Health
Nutrition 2(1): 2333.
Cortis JD (1997) Nutrition and the hospitalized patient. British Journal of Nursing
6(12): 66674.
Guenter P, Jones S, Ericson M (1997) Enteral nutrition therapy. Nursing Clinics of
North America 32(4): 65168.
Lord LM (1997) Enteral access devices. Nursing Clinics of North America 32(4):
685704.
Perry L (1997) Nutrition: a hard nut to crack. An exploration of the knowledge, attitudes and activities of qualified nurses in relation to nutritional nursing care.
Journal of Clinical Nursing 6(4): 31524.
White G (1998) Nutritional supplements and tube feeds: what is available? British
Journal of Nursing 7(5): 246, 24850.
234
CHAPTER 10
Elimination
Clare Bennett and Barbara Workman
perform urinalysis
obtain the following specimens: mid-stream urine; catheter
specimen of urine; faecal specimen collection; and 24-hour urine
collection
assist with toileting, using a toilet, bedpan, urinal and commode
apply a penile sheath
perform catheter care
carry out fundamental aspects of stoma care
care for the patient who is experiencing nausea and vomiting.
Elimination
Alterations in the usual pattern of elimination may be related to a wide
variety of factors including:
reduced mobility
infection of the gut and/or urinary tract
medication
235
neurological dysfunction
confusion
emotional disturbances
disease in another system resulting in dysfunction of gastrointestinal or urinary system (e.g. diarrhoea due to hyperthyroidism).
Assessment of the usual elimination habits is therefore vital in identifying the underlying problem and planning care appropriately. This
should be approached delicately since elimination is a deeply intimate
and personal issue for the majority of people. Privacy should always be
provided and sensitivity shown in addressing the following topics:
Terminology
There are a number of terms that are used in hospital that patients
and junior staff may not be familiar with. Here are some examples.
BNO
BO
defaecation
emesis
236
Elimination
frequency
haematemesis
haematuria
HNPU
melaena
Elimination
Equipment
Reagent strips and bottle. Check that these are in date and have
been stored with the top firmly closed to prevent moisture coming
into contact with the reagents.
Receiver.
Watch with second hand.
Pen for use in sluice.
Results sheet/piece of paper.
Gloves and apron.
Procedure
Prepare equipment.
When Mrs Adams is able, ask her to void into the receiver.
Placing a bedpan liner inside the toilet seat may do this most easily. Patients may be able to void straight into a clean universal
container. This is desirable since it reduces the chances of contaminating the sample.
Figure 10.1
Urinalysis.
Elimination
such as blood cells, casts, pus and bacteria through the use of a microscope; culture involves incubating the sample to check for the growth
of organisms, and sensitivity examines which treatments can be used
to remove the organisms.
When obtaining an MSU specimen, the aim is to catch the middle part of the flow of urine in a single void. Since it is likely to be used
for MC and S it is important that the specimen does not become contaminated with bacteria from the genital area. However, the value of
cleansing the perineal/meatal area before collection of the specimen
is debated in the literature. According to a meta-analysis by Brown
et al. (1991), there is some doubt regarding the effectiveness of
perineal/meatal cleansing. Baillie and Arrowsmith (2001) contend
that such cleansing may not be necessary since the first part of the
stream of urine should flush the urethra free from micro-organisms and
urine should not become contaminated from the perineum if there is
sufficient flow. This appears to be a sensible argument, but there is a
lack of evidence available to support or refute this. It is therefore
advised that you follow local policy until further evidence becomes
available.
may be difficult to obtain an MSU specimen from Mrs
TIP! ItAdams
because of her incontinence. It may help to give her a
drink, and then half an hour later take her to the toilet in the
hope that she will be able to void. You may need to help her
catch the specimen.
Equipment
Procedure
Prepare equipment.
Instruct or assist Mrs Adams to cleanse the perineal area as per
local policy.
241
Ask Mrs Adams to void and discard the initial stream of urine,
then collect the middle part of the stream of urine in the sterile
container, and then complete urinating in toilet/commode/bedpan. If Mrs Adams requires assistance, the nurse should wear
gloves and an apron.
Assist Mrs Adams in making herself comfortable and to wash her
hands.
Label the container clearly with Mrs Adamss name, identity
number/address, date of birth, date and time collected, and examination required. Place in plastic specimen bag.
Place specimen in refrigerator and ensure that it is transported to
the laboratory promptly.
Remove gloves and apron.
Wash hands.
Document collection of specimen in Mrs Adamss notes.
242
Elimination
Evaluation
Has the cause of incontinence been identified? Has Mrs Adams been
able to understand and cooperate with all investigations?
urine collection.
Goal: Mrs Adams will be able to carry out a 24-hour urine collection.
When the collection is started, Mrs Adams should discard the first
sample. The time this sample was passed should be noted on the
243
Evaluation
Did Mrs Adams manage to collect a 24-hour sample without any
problems?
244
Elimination
abdominal surgery.
Problem: Mrs Holder is at risk of acquiring an infection of the urethra
Equipment
Soap.
Warm water.
Disposable wipes.
Clean towel.
Towel and plastic sheet to protect bed linen.
Procedure
245
Equipment
246
Non-sterile gloves.
Apron.
Elimination
Procedure
Prepare equipment.
Explain the procedure to Mrs Holder.
Screen the bed if Mrs Holder requests this or if she needs to be
exposed in order to allow access to the drainage bag.
Wash and dry hands and put on gloves and apron.
Clean the outlet tap of the bag with an alcohol swab and allow it
to dry.
Open the tap allowing the urine to drain into the receiver. Ensure
that the tap does not touch the receiver or the floor and that your
gloved fingers do not touch the exit point.
Close the tap and wipe it with the second alcohol swab.
Position the bag so that it does not touch the floor and is in a comfortable and discreet position.
Cover the receiver, take it to the sluice and, if required, measure
the urine.
Dispose of urine and disinfect or dispose of receiver as per local
policy.
Remove gloves and apron.
Wash and dry hands.
Document volume on fluid balance chart if required.
Report any abnormalities in odour, volume, colour or consistency
of urine to a senior colleague.
catheter bag stand will prevent contact of the port with the floor, thus
reducing the risk of infection. The patient will appreciate discreet
placement of the bag beside the bed or when mobilizing to maintain
her dignity.
no longer required
to be replaced with a new one
if urine is not flowing freely and all attempts to clear a blockage
are unsuccessful
urine is bypassing the catheter, causing leakage.
Catheters should be removed as soon as possible, as the risk of infection increases with each additional day that they are in situ (Wilson
1995). Alternatives to long-term catheterization, such as supra-pubic
248
249
Elimination
Equipment
Receiver.
10 ml syringe.
Disposable waterproof pad.
Clinical waste bag.
Specimen pot, needle and syringe for CSU if required (see page 250).
Gauze swabs or tissues.
Apron and gloves.
Procedure
ALERT!
If any resistance is felt or if bleeding occurs stop and seek
advice from a senior colleague or doctor.
Wash Mrs Holders skin if urine has spilt onto it and change her
bed if necessary.
Help Mrs Holder to assume a comfortable position and open the
screens around the bed.
Take waste to the sluice and measure urine volume if required.
Dispose of urine and equipment, adhering to infection control
policies.
Remove gloves and apron.
Wash and dry hands.
Ensure that a toilet or commode is nearby, or a call bell if assistance is required.
Document catheter removal and volume of urine, if required.
Monitor urine output and observe for dysuria (pain on voiding)
and haematuria (blood in urine). Advise Mrs Holder to maintain
an oral fluid intake of more than 2 litres in 24 hours.
Equipment
Alcohol swab.
10 ml syringe.
Needle (if required use size recommended by manufacturer).
Sterile specimen container.
Pathology request form.
Gate clamp.
Procedure
250
Elimination
Evaluation
Was a positive result obtained from the CSU? Signs of infection may
include pyrexia, offensive urine and abdominal discomfort, and will
indicate the need to reassess Mrs Holders care.
Patient history: Mrs Bright is an elderly lady who has recently had
Elimination
lavatory. If you are new to an area, try to find out what the
local terms are for toilet facilities so that you can respond
quickly and without embarrassing the patient.
Equipment
Procedure
wiped
Elimination
Figure 10.2.1
Slipper pan.
Figure 10.2.2
Reusable pan.
Figure 10.2.3
Disposable pan
with plastic
support.
Equipment
Procedure
Prepare any manual handling aids and ask for as much assistance
as required to assist Mrs Bright in getting onto the bedpan safely.
Provide privacy by drawing the curtains.
Ask Mrs Bright to raise her bottom and place the wide rim of the
bedpan underneath her buttocks with the narrow area situated
between the legs. If using a slipper bedpan, help Mrs Bright to roll
to one side, place the pan under her pelvis with the handle positioned towards the legs and assist her to roll back onto the pan.
Cover Mrs Bright with bedding and leave her alone to provide
privacy but leave her with the call bell and remain nearby. Ensure
she has toilet paper to hand.
256
Elimination
Evaluation
Has Mrs Bright been able to use the bedpan comfortably? Have
spillages been avoided, indicating that the appropriate sort of bedpan
is being offered?
Collect the urinal, urinal holder and disposable cover and take it
to Mr Solomon.
Show Mr Solomon the urinal and explain its use.
Place the urinal in the holder and place on the side of the bed
nearest to Mr Solomons dominant hand so that he can reach it
easily.
258
Elimination
When Mr Solomon has finished, remove his penis from the urinal,
shaking it a little if necessary to remove any drips. Place disposable cover over the urinal, and place into the holder.
Assist Mr Solomon to adjust his clothing and make him comfortable.
TIP! Silicone sheaths are available for people with latex allergy.
259
Figure 10.3.1
Penile sheath.
Figure 10.3.2
Sheath
draining into
leg bag.
Equipment
Procedure
260
Elimination
Evaluation
Has Mr Solomon retained continence? Has the penile sheath been
effective in collecting urine and keeping him dry and comfortable?
pattern.
261
Constipation
Constipation can be defined as fewer than three bowel movements a
week, though additional symptoms like straining, passing hard stools
and the inability to defaecate when desired, together with abdominal
pain, form part of the diagnosis (Bandolier 1997).
Patients commonly complain of constipation, but they may think
they are constipated because they have not had a daily bowel motion.
As can be seen from the definition, infrequency of defaecation alone is
not an indication of constipation, and may in fact have other causes
such as changes in lifestyle or environment. Many people experience
constipation when away from home but their normal bowel habit
resumes on their return home. Elderly patients may present only with
increased confusion and very few other obvious symptoms, so constipation is worth considering in such circumstances.
The cause of constipation needs to be determined and therefore it
is important to take a history. Important questions to ask are:
262
Elimination
Jones 1994). The history may also find a relationship with one of the
following five areas:
263
Diarrhoea
Diarrhoea is usually related to accelerated movement of contents
through the intestine in addition to a decrease in mixing and absorption, resulting in frequent liquid or unformed stools.
Diarrhoea is associated with many bowel disorders as well as other
disorders that are not associated with the intestine. Intrinsic causes
include:
diverticulitis
faecal impaction with overflow
laxatives
infection
neoplasms
dietary changes
antibiotics.
emotional stress
systemic disorders such as acute infectious disease and uraemia.
264
Elimination
Equipment
Bedpan.
Toilet tissue.
Sterile stool specimen pot with spoon attached to lid, or a sterile
universal container and spatula.
Specimen bag.
Laboratory request form.
Gloves and apron.
Procedure
265
When specimen is ready, put on gloves and apron. Cover specimen and take to sluice.
Uncover specimen and use spoon in lid of container or the spatula to collect a small quantity of faeces. Place this in the sterile
container and secure the lid.
Label the container clearly with Mr Campbells name, identity
number/address, date of birth, date and time collected and examination required. Place in plastic specimen bag.
Dispose of excreta, bedpan and spatula as per local policy.
Remove gloves and apron.
Wash hands.
Place specimen in refrigerator and ensure that it is transported to
the laboratory promptly. If the test is for parasites, the specimen
must be kept warm and delivered to the laboratory immediately.
Document collection of specimen in Mr Campbells notes. Report
the presence of blood, excessive mucus, or parasites.
Elimination
Evaluation
Was the cause of diarrhoea identified from the sample and history? Was
Mr Campbell able to cooperate with all investigations?
Stoma appliances
The word stoma refers to an artificial opening. When surgery is
required to remove part of the bowel or bladder as a result of disease or
trauma, a stoma is formed on the surface of the abdomen to allow
excretion of faecal matter or urine.
A colostomy is an artificial opening of the colon onto the
abdominal surface. It may originate from:
A colostomy is usually sited at the left iliac fossa. If the colostomy exits
from the sigmoid or descending colon, its output will be formed with a
normal faecal odour. If it is sited in the transverse or ascending colon,
the output will be loose and copious with a strong odour.
An ileostomy is an artificial opening of the ileum onto the
abdominal surface. It is usually sited in the right iliac fossa. The output
from an ileostomy (effluent) is very soft and fluid, which necessitates
emptying of the appliance approximately six times per day.
A urostomy is formed when the bladder is removed (cystectomy) and a urinary diversion is raised in the form of a stoma.
inside to prevent urine flowing back up to the stoma which may cause
skin soreness and leakage.
her left iliac fossa. She is to start learning how to care for it herself to prepare for discharge.
Problem: Mrs McCarthy is unable to change her stoma appliance.
Goal: Mrs McCarthy will be able to change her stoma appliance prior
to discharge from hospital.
Elimination
Equipment
Procedure
Prepare equipment.
Protect clothing.
If Mrs McCarthy is wearing a drainable pouch she should empty it
first (see below) to avoid spillage.
Remove soiled pouch by starting at the top of the flange and
gently peeling from top to bottom. Use the free hand to support
surrounding skin.
269
Wash around stoma and surrounding skin using soft wipes. Place
these in rubbish bag.
Thoroughly dry skin with soft wipes. Dispose of wipes.
Check the condition of the stoma and surrounding skin and apply
barrier cream if advised.
If necessary, measure the size of the stoma and make a template.
Using the template cut the flange to the correct size. The flange
should fit snugly around the stoma. If it is too small, the edge of
the flange may cause bruising or bleeding due to friction with the
stoma. If it is too big, excrement may spill onto the surrounding
skin causing soreness and, potentially, skin breakdown.
Remove backing paper from the new stoma bag. Fold the bag in
half so that the flange is rounded. Position the bag onto the stoma
by matching lower edge of opening with bottom edge of stoma.
Fold top half of the flange over stoma and press firmly on the skin.
Ensure that the stoma mucosa is not covered with the flange.
Apply gentle pressure around the flange ensuring that it adheres
to the skin. Check that it is free of creases as these may cause
leakage.
Empty soiled pouch into toilet and discard into rubbish bag.
Wash hands.
Document how Mrs McCarthy coped with the procedure and that
the stoma bag has been changed. Any problems should be reported to a senior colleague.
Equipment
270
A receiver.
Protective sheet/tissue for clothing.
271
Elimination
Tissue paper.
Plastic bag for waste.
Gloves and apron if nurse assists.
Procedure
Prepare equipment.
Protect clothing.
Place receiver under outlet of pouch.
Remove clip/open tap at end of pouch.
Empty pouch contents into container.
Clean outlet of pouch with tissue, going at least one inch inside
the bag. (This is not necessary with a urostomy bag.)
Apply cleaned clip.
Dispose of waste according to local policy.
Evaluation
Can Mrs McCarthy state that she can change her own pouch? Does she
appear confident and able to care for it herself? Is the stoma nurse confident that Mrs McCarthy has mastered the technique to care for her
stoma?
vomiting.
Goals: Mrs Child will not aspirate her vomit.
Minimize Mrs Childs discomfort.
272
Elimination
Evaluation
Has Mrs Childs airway been maintained?
273
Limit Mrs Childs oral intake until she feels less nauseated. Keep
to sips of water or ice only if fluids are permitted.
Accurately record intake and output.
ALERT!
If vomiting is prolonged, Mrs Child may require
intravenous fluids and gastric drainage via a nasogastric
tube. It is essential that her fluid balance chart is
accurately maintained to allow assessment as to
whether these interventions are required.
Evaluation
Did these measures relieve Mrs Childs discomfort? Were anti-emetics
effective?
Further reading
Black P (2000) Practical stoma care. Nursing Standard 14(41): 4753.
Getliffe K, Dolman M (1997) Promoting Continence: a Clinical and Research
Resource. London: Bailliere Tindall.
Metcalf C (1999) Stoma care: empowering patients through teaching practical skills.
British Journal of Nursing 8(9): 593600.
Sander R (1999) Promoting urinary continence in residential care. Nursing Standard
14(1315): 4953.
Thomas S (2000) New continence guidance. Primary Health Care 10(6): 2021.
Thomson I (1998) Teaching the skills to cope with a stoma. Nursing Times 94(4):
5556.
274
CHAPTER 11
Aseptic procedures
Barbara Workman
The last two procedures will require supervision in practice until you
are competent to undertake them independently.
Asepsis
Asepsis can be defined as the prevention of microbial contamination
of living tissue or fluid or sterile materials by excluding, removing or
killing micro-organisms (Xavier 1999), the aim being to prevent
infection. Aseptic technique is the collective term for methods used to
maintain asepsis, and is designed to interrupt the routes of transmission
275
Sterilized equipment
When a patients skin or mucous membrane is broken due to an invasive procedure, such as a surgical incision or an intramuscular injection, infection is able to bypass the bodys natural defences. Therefore
all equipment used to penetrate the bodys natural defences should be
sterilized before use. If equipment cannot be sterilized, then disinfection, which removes harmful micro-organisms, is used to prevent the
transmission of infection. For example, a sterile catheter is used to
empty the bladder, but hands cannot be sterilized and must be disinfected before inserting the catheter.
Trolleys are usually disinfected before commencing dressings
or other aseptic procedures by daily cleaning with warm water and
276
Aseptic procedures
integrity
evidence of sterility
secure seals
expiry date.
Non-touch technique
A non-touch technique has been developed to prevent contamination
of the area from micro-organisms on the hands. Historically, forceps
have been used in dressing procedures, but Bree-Williams and
Waterman (1996) found that their use was often incorrect and confused. Evidence suggests that forceps can damage delicate tissues and
be less effective when cleaning an area than a sterile gloved hand
(Tomlinson 1987) or irrigation, and therefore the use of forceps in
aseptic dressing procedures is declining, although for some delicate
manipulative tasks, such as removing sutures, forceps are useful.
Non-touch technique also means that any equipment that is used
in an aseptic procedure will remain sterile only when touched by
another sterile object. For example, while a needle and syringe are
assembled, the barrel of the syringe and the hub of the needle are nonkey parts and can be touched by hand, but key parts of the equipment
such as the needle remain sterile until used during the procedure.
When preparing and using a sterile field, there should be careful placement of the sterile equipment so contamination is kept to the minimum (Figure 11.1).
Implements such as forceps and syringes should be placed so that
the area to be handled is at the edge of the sterile field and near the
nurse so that stretching over the equipment is not necessary. The tips
of equipment expected to touch the swabs should not touch each
other.
277
Clean swabs and dressings can be placed in an area of the sterile field
so that they are well away from the other equipment, but are ready for use.
278
Aseptic procedures
When using an examination couch for procedures, a protective disposable paper sheet should be changed between patients, and the
couch should be disinfected daily or when visibly contaminated.
The bedclothes should be protected with a waterproof sheet or
absorbent pad to prevent irrigation fluid seeping through bedclothes and contaminating the mattress (Perry and Potter 1998).
Self-contamination
A patients own flora from the gastro-intestinal tract, skin or respiratory tract may infect a wound or an intravenous or urinary catheter
(Ayliffe et al. 1999). Helping a patient maintain personal cleanliness,
such as using an antiseptic skin preparation before a procedure, offering handwashing facilities after toileting, and using separate wash
cloths for face and perineal areas will reduce this risk.
279
Handwashing
Effective handwashing, following infection control guidelines (see
Chapter 3), will reduce contamination risks between patients, and is
the single most important activity to prevent transmission of infection.
There is confusion as to how often and at what junctures handwashing
should occur during an aseptic procedure, which results in ritualistic
and/or contradictory practices (Bree-Williams and Waterman 1996).
If considering the principles of asepsis, the following can be used
as a guide to handwashing during an aseptic procedure:
280
Aseptic procedures
A dressing pack containing a dressing towel, gauze swabs, and gallipot for irrigation fluid; possibly also including waste disposal bag,
forceps, or sterile gloves.
Cleaning lotion, such as sterile saline, or prepacked irrigation device.
10 ml syringe.
Receiver/jug containing hand-hot water for warming the irrigation solution.
Sterile disposable gloves.
Alcohol hand rub.
Tape.
Additional dressings and wound care products as prescribed.
Clean scissors for cutting tape. Scissors that have been washed in
detergent and dried, or cleaned with an alcohol swab, may be used
to cut tape. If scissors are required to cut dressings, for example, to
make a keyhole shape, then they should be sterile.
Receiver to collect irrigation fluid if required.
Waterproof protection for the bed if irrigation is required.
Procedure
Clarify the procedure required from the nursing notes. Check for
special instructions, such as the type of dressing to be used, to
enable appropriate equipment to be selected. Some wounds may
require a regular photographic record to monitor progress, or a
wound map may be required.
281
282
Identify the Mrs Cameron by name and gain her verbal consent
for the procedure. This ensures her cooperation. Ensure you maintain her privacy and dignity by drawing the curtains while checking the current dressing to find out whether additional equipment,
such as extra gauze, will be required. Check the type of tape securing the dressing and observe for any discomfort or inflammation
in the area so that an appropriate hypoallergenic fixture is used.
Assess Mrs Camerons pain score. If necessary, administer analgesia prior to the dressing. This will allow the analgesia to begin to
work by the time the dressing is ready to commence.
Offer toilet facilities to ensure comfort during the procedure.
Position Mrs Cameron comfortably, maintaining her dignity, privacy and warmth at all times. If there is likely to be only a short
interval before you return to commence the procedure, close the
curtains and position the bedcovers for easy access to the site. If
the wait is likely to be more than 510 minutes, dont close the
curtains until the equipment is ready: a long wait behind curtains
can be worrying for some patients, and may increase anxiety.
Ensure that all your jewellery is removed other than a wedding
ring. This ensures that hands can be washed effectively. Nails
should be short and clean.
Ensure hair is tidy and clipped out of the face. Hair can harbour
micro-organisms, and touching it during an aseptic procedure will
contaminate the hands.
Wash hands with a socially clean wash. A clean, disposable apron
should be worn for each procedure.
Ensure the trolley is physically clean and has been washed with
detergent that day.
Gather required equipment (see above), and check for sterile
seals, integrity of packaging and expiry dates. Place on the bottom
of the trolley and transport to the patient.
The curtains should be closed and Mrs Cameron positioned comfortably. If the bed height or couch can be raised, position it at
about waist level, which should be a comfortable height for working at in order to reduce back strain.
Ensure a good light source so that you can see the area to be
worked on clearly.
Aseptic procedures
Position the trolley beside Mrs Cameron, and on the side nearest
to the area that is to be worked on, preferably so that her face and
expression can be observed during the procedure. You can see
whether she is suffering any undue distress during the procedure
that could be relieved by explanation and reassurance.
Open the dressing pack and slide the inner pack onto the top of
the trolley. If there are forceps, an instrument bag, or a waste bag
tucked into the packaging, take out and put on one side of the
trolley.
Wash hands with a disinfection wash and dry thoroughly.
Consider the outer inch of the sterile towel as unsterile; hold
about an inch of the corners of the pack. Start with the corner furthest from you, open outwards and straighten out, then the sides,
and then the corner nearest you, until the sheet is stretched out
flat (Figure 11.2.1). This prevents contamination of the sterile
field. Adjust the sterile field so that it is square.
Figure 11.2.1
Straighten out
sterile towel.
283
Lay out the area as in Figure 11.1 (page 278) by placing your hand
inside the disposal bag (Figure 11.2.2), and positioning the sterile
equipment. Forceps may be used to arrange the sterile field instead
of the waste bag, and then placed carefully to one side on the sterile field so that the rest of the equipment is not contaminated.
Figure 11.2.2
Using disposal
bag to position
equipment.
Figure 11.2.3
Opening
additional
equipment.
284
Aseptic procedures
Lotions should be poured carefully from the side. If using a multidose bottle the label should turn away from the pouring side to
prevent drips (Figure 11.2.4). If forceps are being used, a gallipot
may be picked up and held to one side, away from the sterile field,
while the lotion is poured in.
Figure 11.2.4
Pouring lotions
from a sachet.
Open sterile gloves and place on top of the sterile field (see Figure
11.4 below).
Loosen tape on the dressing.
Place your hand inside the sterile bag, and remove the old dressing, discreetly observing the discharge on the wound dressing on
removal.
Gather all dressing material up into the bag (Figure 11.3), turn
inside out and secure on the trolley below the level of the sterile
field, but on the same side as the dressing to allow easy disposal of
waste during the procedure.
If forceps are used to remove the old dressing, they are then
returned for resterilizing if metal, or discarded.
Clean hands either by a disinfection wash or alcohol rub. Dry
thoroughly.
Put on sterile gloves.
285
Figure 11.3
Removing old
dressing.
286
Assess the wound: observe the wound and surrounding area for
inflammation, swelling, or discharge. Do not allow the wound to
remain uncovered for too long as the temperature will drop and
interrupt healing.
If the skin around the wound needs cleaning, it can be swabbed by
gauze swabs slightly moistened with sterile saline. The wound
should not be swabbed with gauze or cotton wool as fibres may
enter the wound bed, and cause a foreign body reaction (Briggs et
al. 1996).
To clean around a wound, wipe from top to bottom, or from clean
area to dirty if that is more obvious, using one wipe for each swab.
If the wound needs cleaning, fill a 10 ml syringe with sterile saline,
or use a prepacked irrigation device.
Placing the sterile receiver below the wound to catch the flow,
irrigate the wound with the syringe, ensuring that it does not
touch the wound. The pressure at which to irrigate has not been
confirmed (Oliver 1997) but should be sufficient to flush away
surface debris without causing trauma. If a small irrigation only is
required, fluid may be collected by holding a gauze swab below the
wound.
Dry the surrounding skin with dry gauze, working from top to bottom or clean to dirty as before.
Position the prescribed dressing and secure. Tape pieces should be
cut individually and applied, but the tape should not be carried to
the wound as it may become contaminated.
Aseptic procedures
Evaluation
Mrs Camerons wound heals by first intention (i.e. without evidence of
infection).
Open outer packaging and allow contents to slip onto flat surface
(Figure 11.4.1).
Following disinfection handwash and thorough drying, open inner
packaging
Using your non-dominant hand, pick up the opposite glove
(Figure 11.4.2) by grasping the exposed inside of the cuff (i.e. left
hand picks up right glove, or right hand picks up left glove).
Pull the glove onto your dominant hand, keeping your thumb
folded across your palm to avoid touching the sterile outside of the
glove (Figure 11.4.3). Hold the cuff on the inside until your fingers have entered the appropriate glove fingers and wriggled into
place, then allow the cuff to unroll a little (Figure 11.4.4).
287
(1)
(2)
(3)
(4)
(5)
(6)
Aseptic procedures
Using your gloved hand, slip your finger under the cuff of the
other glove to pick it up (Figure 11.4.5). Slide your non-dominant
hand into the glove, keeping the thumb tucked in until it is fully
covered. The dominant hand can release the glove when placed
correctly. Be careful not to contaminate the fingers when straightening the cuffs of either hand (Figure 11.4.6).
The gloves can be adjusted to fit comfortably by interlacing the
fingers of both hands and smoothing the material. The gloves will
remain sterile so long as they only touch sterile materials.
Wound drains
Wound drains are designed to aid drainage of fluids such as pus, blood,
or exudate from a body cavity. Accumulation of such fluids increases
the risk of infection and may delay wound healing, but the presence of
a drain may act as a conduit for micro-organisms (Briggs 1997). Manley
and Bellman (2000) suggest that drains should be removed in the following circumstances:
when the drain no longer fulfils its function, and drainage is minimal or nil
suction drains should be removed when there is less than 50 ml
drainage in 24 hours
when an abscess cavity is confirmed by radiology as being closed
when there is a risk of complications occurring due to the location
and length of time in situ.
289
Procedure
290
Prepare for procedure following the steps described for the aseptic
dressing technique (page 281) up to the stage of wound assessment.
Expose the wound drain site, and clean the surrounding skin if
necessary.
A drain may be repositioned by removing the suture that is securing it in position. Identify the suture holding it in situ and, lifting
it with the sterile forceps, cut the suture under the knot, next to
the skin, and gently remove the suture.
Withdraw the drain the prescribed distance (usually 23 cm),
warning the patient that she may experience a pulling sensation.
Take a gauze pad and with the non-dominant hand hold it at the
drain site, applying slight counter-pressure to the skin around the
wound. With the other hand, gently pull the drain. If resistance is
felt or the patient complains of discomfort, pause and slow down.
Encourage the patient to take deep breaths to help her relax
whilst you shorten the drain.
Aseptic procedures
Insert the sterile safety pin through the drain at the new length to
prevent it slipping back into the wound.
Dry the skin around the wound with gauze swab.
A keyhole dressing (Figure 11.5) is applied around the drain, and
additional gauze placed over the drain and secured.
Figure 11.5
Keyhole
dressing.
Procedure
Prepare for procedure and position the patient following the steps
described for the aseptic dressing technique (page 281) up to the
stage of wound assessment.
If the drain is by vacuum, discontinue the vacuum by clamping
the drain.
Expose the wound drain site, and clean the surrounding skin if
necessary.
If a suture is still in situ, identify the suture and, lifting it with the
sterile forceps, cut the suture under the knot, next to the skin, and
gently remove the suture.
Warn the patient that she may experience a pulling sensation as
you remove the drain.
Take a gauze pad and with the non-dominant hand hold it at the
drain site, applying slight counter-pressure to the skin around the
wound. With the other hand gently pull the drain out. If resistance is felt or the patient complains of discomfort, pause and slow
down. Encourage the patient to take deep breaths while you
remove the drain.
Discard the drain into the waste bag, taking note of the colour or
odour of any discharge. If there are signs of infection, place the
drain in a specimen jar to send for microscopy and culture.
Apply gentle pressure with a gauze swab until any bleeding or
drainage from the site has stopped, and then apply a sterile dressing.
Complete the aseptic procedure as described on page 286.
Record the type and amount of drainage, and the condition of the
wound.
Evaluation
Has Mrs Camerons wound drain been effective? Are there any signs of
fluid collecting internally i.e. evidence of haematoma (bruising),
swelling, heat or pain? Is the wound healing as expected?
292
Aseptic procedures
Sutures
Wound closures such as sutures and staples are used to hold wound edges
together in apposition to promote healing without infection. Before
removal, it is necessary to determine the type of wound closure so that the
correct removal technique is used and also the appropriate equipment,
e.g. a staple or clip remover, scissors or stitch cutter. This should be written in the nursing notes and surgical record. The timing of removal
depends on the position of the wound. For example, facial sutures may be
removed within 3 to 5 days, but abdominal retention sutures may remain
until 1421 days post-operatively (Torrance and Serginson 1997).
The main principle to remember when removing sutures is that
any part of the suture that has been exposed on the skin surface should
not travel under the skin as it is removed, since it is likely to take surface micro-organisms into the wound area. This means that cutting the
suture must be carefully planned (Figure 11.6). Never cut both ends of
a visible suture or you will not be able to extract the suture from below
the skin surface.
or staples are removed using a specific clip or staple
TIP! Clips
remover, which may differ depending on the type of skin closure used. Check by reading the patients notes before you
start the procedure that you have the correct instrument
available.
293
Procedure
Prepare for procedure and position the patient following the steps
described for the aseptic dressing technique (page 281) up to the
stage of wound assessment.
Inspect the wound for evidence of healing. If there are signs of
inflammation or discharge consult with the nurse in charge to
determine the appropriate strategy for removal, and take a wound
swab for microscopy and culture before proceeding.
Lift the suture knot with forceps, cut the suture under the knot
nearest the skin and lift upwards, supporting the skin with the nondominant hand as the movement pulls on the wound (Figure 11.6).
Discard. For long or deep wounds alternate sutures are removed first
to ascertain whether the wound has healed consistently throughout.
294
Aseptic procedures
Figure 11.6
Cutting sutures.
Figure 11.7
Using a clip
remover.
If the wound is healing well and skin edges are healed the wound
closures may be removed. Some patients prefer a dry dressing (as
a comfort and protection measure) over the wound for a few days
until the scab has fallen off, depending on the location of the
wound.
Complete the procedure as described before for the aseptic dressing technique (page 286).
Evaluation
Have Mrs Camerons wound closures been removed safely and completely and is her wound healing well?
295
Equipment
Procedure
296
Prepare for procedure following the steps described for the aseptic
dressing technique (page 281) up to the stage of wound assessment.
Explain to Mrs Cameron why and how you are going to take a
swab and how it will help her recovery.
Remove wound dressing. If infection is suspected, the wound and
the surrounding skin may be inflamed, hot and painful, with a
purulent exudate from the wound itself.
Open the wound swab and wipe some exudate onto the swab
(Figure 11.8). Take care not to touch the surrounding skin or to
contaminate the swab or yourself. Provided a non-touch technique is maintained, wearing gloves is not necessary (ANTT).
Replace the swab carefully into the transport container or transport medium, depending on local policy requirements, without
touching the sides.
Aseptic procedures
Figure 11.8
Taking a wound
swab.
Evaluation
Mrs Camerons wound swab will provide sufficient bacterial growth
when cultured to identify the type of infection to enable appropriate
treatment to be prescribed.
Position and prepare the patient, and support her. You may be
asked to help her maintain a particular position or hold her hand
during the procedure.
If you are required to open the sterile field, ensure that you have
washed your hands with a disinfection wash between positioning
the patient and assisting with the equipment.
Open additional packs as required, such as gloves, needles and
syringes. The pack should be opened by peeling back the packaging, and the contents carefully slipped onto the sterile field
(Figure 11.4), or taken from you by the operator. Be careful not to
drop contents from a height as they may slip off the sterile field
and onto the floor.
When tidying up afterwards first identify any sharps and make safe
by disposal into the sharps box or by putting in an obvious location, such as a gallipot, for disposal immediately on leaving the
location, before other equipment is discarded.
Ensure the patient is left clean, comfortable and with the call bell
within reach.
If any observations are to be maintained following the procedure,
ensure you start and continue them and record on appropriate
record sheet.
Ensure any specimens taken during the procedure are labelled and
packaged appropriately and have appropriate request forms completed and signed to accompany the specimen.
Aseptic procedures
This reinforces the importance of ensuring you are adequately supervised when learning clinical skills.
It is only recently that female nurses have begun to catheterize
male patients. Milligan (1999) suggests that this is less likely to be
related to the difficulty of the procedure than to the psychosexual connotations that are linked with male genitalia, masculine body image
and sexuality, and suggests that catheterization may be perceived as an
invasion of an individuals sexuality. Experience suggests that some
women may find their sexual beliefs and gender attitudes challenged by
a male nurse catheterizing them. Space precludes full discussion of
these issues within this chapter but when caring for a patient with a
catheter, you need to be sensitive to these issues and be concerned to
support a patients dignity, privacy and perception of body image and
sexual identity during catheterization and catheter care.
300
Aseptic procedures
Procedure
Male: Mr Gregg may lie supine or at 45, with the genital area
exposed.
Fold bedclothes away from genital area and place disposable
waterproof pad under the buttocks.
Position a good light source such that the genital area is well
illuminated.
TIP! procedure
Remember that your head may obscure it while you are working, and so it should be placed where the site can be clearly
seen but where your head will not block the light, or hit it if
you change position.
Open the catheter pack and place inner contents onto the trolley
surface.
Wash hands with a disinfection wash and dry thoroughly.
Lay out the sterile field, ensuring that the gallipot is placed nearest to the patient to prevent fluid from contaminating the sterile
area (Figure 11.2).
Empty saline sachet into the gallipot.
Open catheter and place in its inner wrapping in the receiver.
Draw up the 10 ml water (or required amount of fluid to fill the
balloon) into the syringe and place to one side.
For female patients, squeeze about 3 cm of lubricant/anaesthetic
gel onto a piece of gauze and place to one side.
Prepare the lubricant/anaesthetic gel according to manufacturers
instructions.
302
Open the catheter drainage bag and, ensuring the connecting end
remains covered, attach the bag to the bed on a hanger, and place
the connection within reach.
Open two pairs of sterile gloves on the sterile field.
Place sterile dressing towels between and over the patients thighs.
Aseptic procedures
Figure 11.9
Separation of
the female labia.
303
WARNING!
If you have difficulty identifying the urethral meatus due to
phimosis (prepuce cannot be drawn back over the glans penis)
do not continue, but summon expert assistance.
304
M: instil 20 ml anaesthetic gel (Addison 2000) into the urinary meatus using the applicator provided. To prevent gel from being expelled
from the urethra, hold the tip of the glans penis firmly with the nondominant hand, and wipe the underside of the penis downwards to
allow the anaesthetic to take effect along the urethra. While the
anaesthetic gel is taking effect, place penis on a piece of gauze.
M: remove the top pair of gloves.
Aseptic procedures
TIP! den release of a large amount of fluid from the bladder may precipitate hypovolaemic shock. Careful observation of the amount
and speed of urine drained may detect an early change in the
patients condition as well as pulse and blood pressure record-
The final stages in this procedure apply for both males and females.
Attach the catheter to the drainage bag, and ensure the bag is
hung below the level of the bladder at all times to prevent backflow of urine. Tape the drainage bag to the thigh to prevent it
pulling on the urethra.
A specimen of urine may be taken from the sterile receiver or
catheter wrapper and sent for microscopy and culture if required.
Place the equipment onto the top of the trolley and position the
patient comfortably, ensuring that all immediate needs are within
reach.
Place all waste into bag, including discarded apron and gloves.
Leave the bed area.
Discard waste and wash hands.
305
Evaluation
Is the urine flowing freely? What is the colour, concentration, and
amount? Can you smell any evidence of infection?
For further catheter care, see Chapter 10.
Further reading
AORN (1996) Recommended practices for maintaining a sterile field. AORN Journal
64(5): 81721.
Ayliffe GAJ, Babb JR, Taylor LJ (1999) Hospital-Acquired Infection: Principles and
Prevention, 3rd edn. Oxford: Butterworth-Heinemann.
Bree-Williams FJ, Waterman H (1996) An examination of nurses practices when performing aseptic technique for wound dressings. Journal of Advanced Nursing
23(1): 4854.
Briggs M, Wilson S, Fuller A (1996) The principles of aseptic technique in wound care.
Professional Nurse 11(12): 80512.
Manley K, Bellman L (eds) (2000) Surgical Nursing: Advancing Practice. Edinburgh:
Churchill Livingstone.
306
CHAPTER 12
Principles of
pre- and postoperative care
Aims and learning outcomes
This chapter outlines the key principles of preparation of a patient for
a surgical or investigative procedure requiring sedation or anaesthesia,
and summarizes the post-operative care required for a safe recovery. By
the end of the chapter, you will be able to:
undertake safe physical preparation of a patient to prevent complications arising from an anaesthetic or surgical intervention
be aware of some key psychological factors to be addressed prior to
surgery
receive a patient following recovery from anaesthesia and continue their immediate post-operative care, providing safe recovery
from surgical intervention
identify the nursing interventions required to prevent post-operative
complications.
Introduction
Admission for surgery can be planned or as an emergency. Planned
surgery means that the patient has been waiting on a list, possibly for
some time. The anticipated outcome of the surgery is expected to be
good as the surgery is likely to relieve unpleasant or uncomfortable
symptoms, or determine their cause. There will have been an opportunity for the patient to make psychological preparations and to begin to
307
Pre-admission clinic
A visit to a pre-admission clinic about 10 to 14 days before an operation provides the opportunity to undertake a thorough pre-operative
assessment prior to admission (Torrance and Serginson 1997). These
clinics reduce unnecessary time in hospital waiting for surgery and
allow familiarization with the forthcoming procedure so reducing anxiety and preparing for speedy recovery.
Torrance and Serginson (1997) summarize the aim of pre-admission clinics as being to:
ted for a total abdominal hysterectomy. She has been a smoker for
30 years, but while waiting for this operation she has managed to
reduce her cigarette intake to 510 a day.
Problem: Ms Bailey requires pre-operative preparation to prevent
complications from a general anaesthetic.
Goal: Ms Bailey will have an uncomplicated recovery from a general
anaesthetic.
calculate drug dosages and estimate the patients nutritional status (see
Chapter 9).
310
311
Pre-medication
Pre-medications to induce relaxation and reduce anxiety are rarely
administered nowadays as their actions prolong the patients hospital
stay, particularly in day cases (Dawson 2000). Additionally, modern
anaesthetics are rapid-acting and no longer need a sedative premedication, so if pre-medications are given they are more likely to be
used to prevent complications from surgery (see Nursing problem
12.2). Emergency cases may have been given analgesia prior to surgery
and this may also sedate the patient.
Evaluation
Was Ms Bailey safe for anaesthesia? Did she fast for an optimum
period? Can she undertake leg and coughing exercises effectively?
312
Skin preparation
Pre-operative skin preparation aims to reduce the presence of dirt and
transient micro-organisms, particularly Staphylococcus aureus, which
has been found to be the most common cause of wound infection
(Simmons 1998). Usually a bath or shower using an antiseptic wash on
the day is sufficient, but some surgeons require several consecutive
days preparation with antiseptic solutions to reduce skin flora. Studies
to confirm the optimum preparation for every operation are as yet
inconclusive, although it is known that washing with skin antiseptics
prior to surgery does reduce wound infections.
If possible, hair should be washed pre-operatively to reduce the
possibility of it acting as a reservoir for infection. Special attention
should be paid to cleaning the umbilicus and finger- and toenails, and
nail varnish should be removed (Torrance and Serginson 1997).
The debate concerning hair removal before surgery also remains
inconclusive. Shaving is known to cause abrasions which are likely
to encourage bacterial proliferation. Less infection occurs if the skin
313
314
Transfer to theatre
Before transfer to theatre there is usually a checklist to be completed.
The following is an example:
315
Evaluation
Was the checklist completed fully? Was Ms Bailey fully prepared for
the surgical procedure?
316
Evaluation
Has Ms Bailey made mental adjustments to her condition? Has she
received sufficient information for her needs? Does she need additional information or counselling?
Post-operative care
Preparation should be made on the ward to receive a patient on return
from theatre:
Suction and oxygen should be placed beside the bed and checked
to ensure they are working.
IV stands or bed cradles should be placed ready for use.
The bed space located in a position for ease of observation.
The bed is prepared with clean linen.
317
awake.
Baseline observations
Observations of temperature, pulse, respirations and blood pressure
should be taken to detect early signs of shock, hypoxia or other complications. These observations will become less frequent as Ms Baileys condition improves, but will need to be closely monitored on her return to
the ward. A rise in temperature after a day or so may indicate the development of other complications such as a wound or chest infection.
318
Fluid balance
Many types of surgery require fluid replacement by IV therapy (IVT),
and guidelines for IV care should be followed (see Chapter 7). The IV
site should be checked on handover so that the ward nurse is familiar
with the current progress of the regime, and the condition of the IV
site. Further IV fluids should be prescribed for administration on the
ward.
A fluid balance chart may be commenced in recovery or on arrival
on the ward, and all oral or intravenous fluids should be noted. Should
the patient not require IVT, oral fluids should not be commenced until
the patient is fully awake, to reduce potential vomiting and inhalation.
Urine output should be monitored and recorded to ensure that the
kidneys are fully functioning following surgery. If a urinary catheter is
in place output will be monitored to ensure that fluids administered
during surgery are excreted and that the catheter drainage system is
patent. If the patient is not catheterized it should be recorded if urine
has been passed, and on return to the ward the urine output should
continue to be monitored. If urine has not been passed within eight
hours of the operation, urine retention may be developing and every
effort should be taken to encourage the patient to pass urine (see
Chapter 10).
If a nasogastric tube is in place, the drainage and aspirate should
be monitored and recorded so that an accurate fluid balance can be
maintained.
Pain relief
Pain relief can be by opioids, non-steroidal anti-inflammatory drugs
(NSAID) or local anaesthetic (Hutchings 1995). They may be given
orally, rectally, by injection, or by PCA. Sufficient pain relief should be
administered to enable Ms Bailey to move about in bed as necessary
and to rest comfortably. The amount, type and frequency of pain relief
319
Wound
The wound should be observed in the recovery room for signs of leakage or bleeding. Any wound drainage should be monitored, and if there
is leakage through the dressing the wound should have additional
dressings placed on top, rather than disturb the incision and interrupt
clot formation. The wound dressing should be checked at regular intervals on return to the ward to ensure that there is minimal oozing.
Patients who have drainage bottles or bags should have the quantity and consistency of fluid monitored. Gynaecological patients may
have a sanitary towel in place and vaginal discharge and bleeding
should be monitored when other post-operative observations are
recorded.
If there are any abnormalities in any of these aspects of care, they
should be reported to senior staff for reassessment and further intervention.
Evaluation
Has Ms Bailey returned from recovery fully awake and conscious? Is her
pain relief effective? Is her fluid balance satisfactory? Is the wound dry
and comfortable?
no complications.
Goal: Ms Bailey makes a safe and uncomplicated recovery from
surgery.
320
Pain relief
Pain relief should follow the regime prescribed by the anaesthetist.
If inadequate, Ms Bailey will not be able to return to full mobility
quickly and therefore will be at risk of developing complications. Oral
medication should be prescribed and commenced as intramuscular or
intravenous pain relief is reduced.
Mobilization
Early mobilization will promote recovery and early discharge. Again,
adequate pain relief is essential in promoting mobilization. When first
getting up after an operation, the patient should be encouraged to take
it slowly and steadily, as hurrying may cause fainting. Encourage Ms
Bailey to change position in bed to relieve pressure points, stimulate
her circulation and encourage deep breathing and coughing.
Wound care
The wound should be allowed to heal with minimal intervention.
Some studies have suggested that the original wound dressing may be
removed after 2448 hours and a protective film be placed over the
wound for protection and patient comfort (Briggs 1997). Local guidelines for wound care should be followed. The wound should be checked
for signs of infection.
321
Discharge plan
This will include consideration of any special needs like wound dressings, stoma care or if a walking aid is required. Special instructions for
continuing care at home should be given to the patient in writing. For
example, certain exercises may be required to strengthen muscles
weakened during surgery. Information as to when driving, lifting, sexual activity or work can be safely resumed will be helpful for Ms Bailey,
so that she can plan her recovery time at home.
Evaluation
Has Ms Bailey had an uneventful recovery from surgical intervention?
Has she been able to be discharged as planned?
Further reading
Briggs M (1997) Principles of closed surgical wound care. Journal of Wound Care 6(6):
28892.
Dawson S (2000) Principles of pre-operative preparation. In Manley K, Bellman L
(eds), Surgical Nursing: Advancing Practice. Edinburgh: Churchill Livingstone.
Finlay T (1996) Making sense of bowel preparation. Nursing Times 92(45): 3839.
Hung P (1992) Pre-operative fasting of patients undergoing elective surgery. British
Journal of Nursing 1(6): 28687.
Hutchings P (1995) Advances in anaesthesia: some recent developments in techniques
for short stay surgery. British Journal of Theatre Nursing 5(1): 1315.
Jolley S (2001) Managing post-operative nausea and vomiting. Nursing Standard
15(40): 4752.
Mitchell M (2000) Nursing intervention for pre-operative anxiety. Nursing Standard
14(37): 4043.
Seymour S (2000) Pre-operative fluid restrictions: hospital policy and clinical practice.
British Journal of Nursing 9(14): 92530.
Simmons M (1998) Pre-operative skin preparation. Professional Nurse 13(7): 44647.
Thomas N (1995) Patient-controlled analgesia. Nursing Standard 9(35): 3135.
Torrance C, Serginson E (1997) Surgical Nursing, 12th edn. London: Bailliere Tindall.
322
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References
330
Index
Accuhalers 2034
acromial process 112
activities of daily living 10, 1215, 196
acute retention of urine 299, 300, 305
administration sets 15961
blood transfusions 171, 1746
enteral feeding 2278
IVT 1457, 149, 1512, 15465
admission 1112, 48, 80, 100, 136, 195
assessment 3, 6, 910, 12, 13, 1518
nutrition 21415, 216
PQRST framework 1112
surgery 30722
adrenaline 191
Aerohalers 2034
Aerolizers 203
airborne organisms 278
alarms 155, 156, 157, 184
alcohol consumption 8, 14, 79
alcohol hand rubs 56
alcohol wipes 42, 11516, 171
IVT 144, 1478
allergies 12, 150, 166, 176, 179, 223,
310
blood transfusions 176, 177
drug administration 96, 102
gloves 57
penile sheaths 259
urinary catheters 299
ampoules of drugs 11516, 122
anaemia 17, 168, 216
Index
333
Index
Index
fats 215
feeding patients 58, 214, 216, 21920
first impressions 67
fixed performance devices 1889, 192
fluid balance 13477, 319
blood transfusions 16777
complications of IVT 1626
drug administration 109
IVT 1345, 1401, 14267
monitoring 13441
nausea and vomiting 135, 136, 139,
274
nutrition 135, 137, 220, 228
overload 1412, 165, 177
post-operative care 318, 319, 320,
321
removal of cannulas 1667
urinary catheters 136, 247, 248,
306
food and eating 24, 26, 29, 1067,
21434
feeding patients 58, 214, 216,
21920
fluid balance 135, 137
infection control 53, 54, 58
inhalers 200
NG administration 1067, 109,
214, 2209
personal hygiene 62, 712
supplements 137
see also nutrition
focused assessment 6, 10 12, 1518
footwear 76
forceps 160, 277, 2801, 2835
suture removal 294
wound drains 290, 2912
foreskin 246, 261, 3045
frequency 13, 14, 237, 259
urinary catheters 249
fresh frozen plasma 168
full blood count (FBC) 308
gag reflex 73, 205, 207, 209
genital area 645, 66, 241, 3012
Glasgow Coma Scale 346
glaucoma 14, 129, 197
gloves 57, 2879
aseptic procedures 275, 277,
27981, 285, 2879, 296, 298
Index
manometer 256
manual dexterity 7, 13, 201, 215,
21718
incontinence 2378, 242
manual handling 87, 2534, 256
mastectomy 24
meatal area 241, 2456, 301, 3034
mechanical pumps 151, 1545, 1567,
166
medication 21, 36, 93133, 191, 226,
233
assessment 4, 12, 14
calculating doses 93, 95, 99100,
102, 310
compatibility with lignocaine 302
decubitus ulcers 867
elimination 235, 238, 2623, 265
infection control 48, 53
nausea and vomiting 273
pre-operative care 31011, 315
respiratory care 179, 191, 196
see also drug administration
Medicines Act (1968) 93
melaena 237
menstruation 7, 257
mercury thermometers 2833
metered dose inhalers (MDIs) 200,
2013, 206
Methicillin-resistant Staphylococcus
aureus (MRSA) 489, 534,
57, 277
microscopy, culture and sensitivity
(MC&S) 193, 232, 2401
IVT 163, 164
urinary catheters 305
wound swabs 294, 2967
micturition see urine and urination
minerals and nutrition 215
Mini-Wright peak flow meter 185
Misuse of Drugs Act (1971) 93, 109
Misuse of Drugs Regulations (1985) 93
mobility 13, 789, 87, 321
assessment 7, 13, 15
complications of bed-rest 7880,
838
constipation 261, 263
elimination 235, 2378, 252, 257,
261, 263
340
Index
Nifedipine 100
nil by mouth 311, 312, 321
drug administration 96, 104
fluid balance 136, 143
PEG tubes 231
non-rebreathable masks 189
non-steroidal anti-inflammatory drugs
(NSAIDs) 319
non-touch technique 276, 2778, 289,
296
nose 50, 534, 178, 223
nursing diagnosis 4, 5
nursing models 5, 10, 12
nutrition 13, 88, 21434, 306, 310,
321
assessment 10, 13, 16, 21416
complications of bed-rest 86, 88
elimination 263, 2645, 271
IVT 1423
see also food and eating
obesity 6, 24, 69, 80
observations 1944, 823, 85, 136,
252
aseptic procedures 286, 287, 298,
305
assessment 5, 67, 16, 18, 1944
blood transfusions 1746
IVT 149, 158, 161
nutrition 219
personal hygiene 67
post-operative care 315, 31718,
320
pre-operative care 30910
respiratory care 17883, 1867,
1935
sputum 1935
urinary catheters 305
occupation 14, 15, 179
oedema 6, 86, 111, 142, 181, 194
oliguria 135, 137
ophthalmic medication 93, 12933
opiates and opioids 102, 263, 319
oral drug administration 93, 1015,
107, 115, 123, 125, 127, 319
oral thrush (candida) 197, 198, 200,
205
oropharyngeal suctioning 178, 2079
orthopnoea 179
osteoporosis 79
otitis media 34
overhydration 135, 1412
oxygen 18793
IVT 165, 166
oral hygiene 71
post-operative care 317, 318
pulse oximetry 178, 1834, 195,
318
respiratory care 178, 1834,
18793, 1958, 211
saturation levels 19, 434
temperature 29
pain 6, 9, 12
aseptic procedures 282, 297
blood pressure 26
blood transfusions 175, 176
complications of bed-rest 823, 86
constipation 262, 263
diarrhoea 265
elimination 236, 238
fluid balance 143, 145
IM injections 117, 11920
infection control 48
IVT 161, 1635
level of consciousness 379, 41
PEG tubes 232
personal hygiene 62, 71
post-operative care 318, 31920,
321
respiratory care 179, 187
urinary catheters 249, 250, 299,
305
wound drains 28990, 292
wound swabs 296
pain relief 31920, 321
assessment interview 8, 12, 14
drug administration 102, 104, 124
IVT 155
pre-operative education 310
wound drains 290
see also analgesia
pancreatitis 221
paracetamol 176
paralysis 24, 36, 62, 76
paralytic ileus 124, 221, 321
341
parasites 2656
Parkinsons disease 100
peak expiratory flow rate (PEFR) 102,
178, 1856, 196
pectoral muscles 182
pelvic floor 238, 242
penile sheaths 235, 25961
pentamadine 196
percutaneous endoscopic gastrostomy
(PEG) 214, 22934
perineal area 635, 67, 257, 279
incontinence 241, 242
rectal drug administration 127, 129
urinary catheters 2456
urine samples 241
peripheral pulse 212
personal hygiene 6076
decubitus ulcers 889
pre-operative care 315
urinary catheters 66, 301
perspiration 87, 135, 272
personal hygiene 612, 667
pestle and mortar 101, 106, 108
pets 279
pH and litmus tests 1078, 239
NG feeding 222, 2245, 227
pharmacy and pharmacists 12, 97, 101,
102, 106, 110
inhalers 201
pharynx 178, 207, 209, 210
Phenytoin 106
phimosis 304
phlebitis 143, 163
blood transfusions 176
IVT 161, 163, 167
phlegm see sputum
phosphate enemas 129
physiotherapy 13, 194, 212, 227
piriton 177
platelets 168
Poisons Act (1972) 93
position 187
aseptic procedures 282, 287, 298
assessment 8, 13, 14
blood pressure 245
drug administration 103, 107, 109,
118, 125, 128
elimination 253, 257, 258
342
IM injections 118
IVT 154
nausea and vomiting 2723
NG feeding 223, 225
nutrition 216
post-operative care 321
pressure sores 867
rectal drug administration 125, 128
respiratory care 187, 192, 196, 198,
212
suctioning 208, 210
temperature 313
urinary catheter 246, 250, 3012,
305
post-operative nausea and vomiting
(PONV) 311, 319
potassium 143, 145, 158
potassium chloride 163
pre-admission clinic 3089
pre-assessment clinic 1718
pregnancy and DVTs 80
pre-medication 102, 312, 315
prescriptions 12, 95, 96, 978, 1912,
217, 2279
blood transfusion 1701, 173
IM injections 115, 11819
incontinence 238
IVT 1445, 149, 153, 1589
lignocaine 302
nausea and vomiting 273
nebulizers 1978
NG drug administration 107,
11011
NG feeding 2279
ophthalmic drug administration
1302
oral drug administration 1034
oxygen 188, 1912
post-operative care 320, 321
rectal drug administration 125, 127,
129
subcutaneous injections 121
pressure-relieving aids 88, 187
pressure sores 859, 215, 314, 321
complications of bed-rest 789,
859
privacy 23, 24, 31, 33, 282
complications of bed-rest 81, 84
Index
constipation 263
drug administration 107, 118, 123,
125, 128
elimination 236, 2524, 256, 258,
261
IVT 167
nausea and vomiting 273
nutrition 217
personal hygiene 64, 689, 70, 75
respiratory care 191
stoma 269
urinary catheters 2467, 249, 250,
300, 301
problem statements 16, 17
prostheses removal 312, 315
protective clothing 478, 50, 51
see also aprons; gloves
protein
nutrition 227
urine 239, 243
providone iodine 54
psychosocial factors 15
pulmonary artery 27
pulmonary embolism (PE) 80, 194,
310
complications of bed-rest 79, 80, 82
pulmonary secretions 188, 20711,
212
pulse and pulse rate 203, 102, 142,
30910, 318
amplitude 212
blood pressure 25
blood transfusions 1746
chest infections 85
hypovolaemia 305
IVT 163, 165
level of consciousness 41
observations 19, 203
PEG tubes 232
radial 213
respiratory care 1812, 186, 196
rhythm 213
pulse oximetry 178, 1834, 195, 318
pupil reaction and size 39
pyelonephritis 244
pyrexia 28, 136, 176
blood transfusions 175, 176
CSU 251
DVT 82
incontinence 238
IVT 1634
PEG tubes 232
radiotherapy 71, 220
rattly chest 181, 207
records and documentation 1011,
1920, 434
aseptic procedures 287, 291, 292,
293, 298
assessment 5, 9, 1011, 1718
blood glucose 423
blood pressure 245
blood transfusions 1745
complications of bed-rest 82, 878
diarrhoea 266
elimination 254, 257, 259, 261
fluid balance 1369, 149, 159,
1612, 164, 167
IM injections 112, 11920
infection control 51
IVT 149, 159, 1612, 164, 167
level of consciousness 36, 39, 41
nausea and vomiting 274
NG drug administration 10910
nutrition 220, 225, 228, 2312
ophthalmic drug administration
130, 132
oral drug administration 102, 104
personal hygiene 67, 6970
post-operative care 318, 320
pre-operative care 310, 312, 314,
315
pulse 213
rectal drug administration 127, 129
respiratory care 1824, 186, 192,
1946, 198
stoma 270
subcutaneous injections 124
suctioning 209, 211
temperature 2834
urinalysis 240
urinary catheters 2467, 251, 306
urine samples 242, 244
recovery 3079, 310, 313
fluid balance 134
infection control 48
343
Index
346
Index
347